Current Drug Safety - Volume 18, Issue 3, 2023

Background: COVID-19 and tuberculosis (TB) are infectious diseases that predominantly affect the respiratory system with common symptoms, such as cough, fever, and shortness of breath, making them dual burdens. Methods: This review will discuss the characteristics of the coexistence of TB and new infectious illnesses to provide a framework for addressing the current epidemic. Currently, there are no clear and significant data on COVID-19 infection in TB patients, they may not respond appropriately to drug therapy and may have worse treatment outcomes, especially if their TB treatment is interrupted. Due to emergence, measurements should be taken to minimize TB and COVID-19 transmission in communal settings and health care institutions were created. For both TB and COVID-19, accurate diagnostic testing and well-designed, and established therapeutic strategies are required for effective treatment. Results: Several health care organizations and networks have specimen transit methods that can be utilized to diagnose and monitor the etiology and progression of COVID 19 and perform contact tracing in developed and underdeveloped nations. Furthermore, patients and health care programs could benefit from increased use of digital health technology, which could improve communication, counseling, treatment, and information management, along with other capabilities to improve health care. Conclusion: Patients with COVID-19 pulmonary/respiratory problems may seek treatment from respiratory physicians, pulmonologists, TB experts, and even primary health care workers. To have prophylactic and therapeutic strategies against COVID-19, TB patients should take the appropriate health care measures recommended by health care professionals/government officials and maintain their TB therapy as indicated.

Background: Alzheimer’s disease (AD) is an age-dependent neurodegenerative disease with progressive cognition and memory loss, insomnia, and other abnormal behavioral changes. Amongst various hypotheses for AD pathophysiology, occupational stress-induced Alzheimer’s has recently been reported in many AD cases. Objective: Studies pertaining to the same suggest that stress leads to insomnia or sleep disruption, which further leads to neuroinflammation due to oxidative stress, both of which are major harbingers of AD. Additionally, overall sleep deficit is associated with progressive cognitive and memory decline, which adds more inconvenience to Alzheimer’s disease. Based on this, any triumphant AD management needs a pharmacological intervention that can not only antagonize the amyloid betainduced neurotoxicity but also correct the sleep-wake cycle disruption. Chronobiotic therapeutics like melatonin offer vital neuroprotective effects by eliciting its action through more than one of the pathologies of AD. This is also bolstered by the finding that endogenous melatonin levels are lower in AD patients. This melatonin replacement therapy can be especially useful in AD treatment, but only in the early phases of the disease and in cases where the melatonin receptors are intact and functioning. Conclusion: To negate such limitations and extend the action and therapeutic efficacy of melatonin- mediated actions towards AD treatment, melatonin analogue like tasimelteon can pose a high therapeutic value in AD treatment superior to that provided by melatonin. This review encapsulates all details about how AD is believed to occur and how current situations influence it, along with how melatonin and tasimelteon act towards treating Alzheimer’s.

Background: The effectiveness of Isotretinoin is superior compared to other acne therapies, particularly in reducing acne lesion counts. Concerns, however, arise relating to the most optimal dosage regimen with the best efficacy and lesser side effect. Objective: We intend to review existing randomized controlled comparative studies of isotretinoin in different regimens. Methods: PubMed, Cochrane, Scopus, and ScienceDirect were searched. The inclusion criteria is the RCT article. Full-text reading excluded articles that did not use GAGS as the method of measurement. Out of 921 articles that were electronically searched, 6 RCTs were extracted and summarized descriptively. After full-text reading, 4 RCTs were included. We then conducted risk of bias assessments for the selected studies using The Cochrane Risk of Bias Tool. Results: Across all trials, low-dose regimens were preferable in all types of acne-owing to its similar efficacy to conventional dose but with fewer occurrence of side effects as well as better patients’ satisfaction and compliance. Furthermore, a continuous low-dose regimen had the best efficacy in comparison to other regimens of low-dose treatment. Discussion: The limitations of our study include a slight difference in dosage between selected studies. Other limitations are that some studies did not explain the side effects and relapse rate thoroughly and did not state the compliance scoring method used. Conclusion: This review recommends continuous low-dose treatment as the chosen regimen for acne vulgaris. However, further evaluation regarding relapse rate compared to the conventional dose is needed.

Background: The risk of sudden cardiac death (SCD) can be increased with the use of drugs. However, it has been described heterogeneously in the literature. Objective: This study aims to systematically review epidemiological studies dealing with druginduced sudden death, describe their methodologies, and summarize the results found. Methods: A scoping review has been carried out using Medline electronic database. The search was limited up to 2020. Epidemiological studies were included, and case reports or case series were excluded. Results: Out of 3,114 potential articles, 74 were included. Most studies originated from North America (40.5%) or Europe (39.2%). Case-control (47.3%) or cohort (40.5%) studies were the most common designs. The data for outcomes and exposure were retrieved mainly from administrative databases (37.8%) or medical charts/hospital discharge reports (32.4%), but most studies used several sources of information. A composite variable of sudden death or SCD, mainly with ventricular arrhythmia, was the most frequently used endpoint. Only 18.9% of the studies included autopsy results to confirm the death. Psychotropic drugs were the most frequently studied. An increased risk of different outcomes for typical antipsychotics, tricyclic antidepressants, domperidone, and antiepileptics is suggested. Conclusion: The methodologies used were highly heterogeneous, and the results were, in general, not conclusive. An improvement of the methodologies is needed to achieve a conclusion regarding the risk of SCD associated with drug use.

Aim: The aim of the study was to assess the impact of never-use list and standardized abbreviations on error prone abbreviations. Background: Abbreviations are commonly used in medical records to save time and space but use in prescriptions, which can lead to communication failures and preventable harm. Prescriptions need to be clear for correct interpretation. Hospitals should implement uniform use of approved abbreviations, such as an approved list or never-use list of abbreviations and symbols. In the hospital under study, there was no system of avoiding error prone abbreviations while prescribing any medication. Hence, an interventional study was performed to quantify and reduce the incidence of error prone abbreviations. Objectives: The main objectives were to determine the incidence of error prone abbreviations, development and implementation of ‘Never-use’ list and standardized abbreviations and finally determine its effectiveness in reducing the error prone abbreviations in the prescriptions. Methods: The study design was pre-post interventional / quasi-experimental design. The settings were inpatient wards of broad specialties of a tertiary care hospital. ‘Never-use’ list and standardized abbreviations were developed by review of relevant literature, existing lists by Institute for Safe Medication Practices and Australian Commission on Safety and Quality in Health Care compared against findings of the pilot study of prescriptions for error prone abbreviations and experts’ input. Poster copies of the lists were affixed in inpatient wards, doctors were educated, and poster pamphlets were distributed. Pre-intervention data was collected by a retrospective closed in-patient medical record review. Post-interventional incidence of error prone abbreviations was determined, and the effectiveness of the same was assessed by using statistical analysis. Results: The incidence of error abbreviations in inpatient prescriptions was 47.5%, and the ‘Never Use’ list of abbreviations led to a statistically significant reduction of error prone abbreviations by 8.2% from 47.5% to 43.6% (P\0.006). Conclusion: ‘Never Use’ lists are effective in reducing the incidence of common error-prone abbreviations, and discipline-wise variation is observed.

Background: Aluminum phosphide (ALP) poisoning is considered one of the health care issues in Iran, which is associated with the mortality outcome of patients. Introduction: According to the ALP poisoning that commonly results in death, we aimed to evaluate the prevalence of ALP pill poisoning by employing register-based research. Methods: In this descriptive cross-sectional study, all selected patients diagnosed and confirmed with ALP poisoning by a specialist and referred to the poisoning ward from the beginning of April 2016 to the end of October 2017 were enrolled, and data were registered in the Disease Registration System by a technical expert for daily follow-up during hospitalization. Results: Approximately 12.4% of patients had neurological problems, with the majority having paresis (68.3%). Self-poisoning with the purpose of suicide was documented for 96.2% of cases, with the most common cause being family problems (54.1%). In 97.3% of cases, the method of contact with the toxic substance was oral. Hypotension, cardiac, and respiratory complications were observed in 25.2%, 30.8%, and 25% of the patients, respectively. The most gastrointestinal symptoms were nausea and vomiting (86.7%). Conclusion: The results indicate that the rate of ALP pill poisoning is relatively high. Suicide is the most important cause of ALP poisoning, which is more common in men under 40 years of age.

Introduction: Between 2005 and 2014, the 12-month prevalence of major depressive episodes among adolescents aged 12 to 17 years increased from 8.5% to 11.3%. Adolescent-onset depression is related to increased risk for depression and suicidal attempts in adulthood. It is known that depression is an adverse effect among adults taking OAM; however, the effect of OAM on adolescents is unknown. Aim: The aim of this study was to describe the relationship between Patient Health Questionnaire 9- Modified (PHQ9-M) scores and OAM use among adolescents. Methods: This study included data abstracted from charts of adolescents aged 12 to 21 years who completed a Kansas Be Healthy wellness appointment at the KUSM-W Peds Clinic in 2017. Odds ratios were used to calculate the relationship between oral allergy medication and gastrointestinal medication use among adolescents and PHQ9-M scores. Results: Of the 425 adolescent charts analyzed, 22% (n=96) had positive PHQ9-M screens (a score of 10 or greater), and 13% (n=56) reported current use of allergy medication and/or GI medications. Adolescents taking oral allergy medication were 1.77 times more likely to have a positive PHQ9-M screen than those not taking oral allergy medication. Among adolescents on allergy medication, there was no difference in PHQ9- M scores based on the drug class (1^st or 2^ndgeneration antihistamine or Montelukast). Conclusion: Healthcare providers must diligently explore OAM/GI use with adolescents during clinical encounters and discuss possible adverse effects of OAM on mood.

Tuberculosis is a challenge in organ transplantation due to the interaction between Anti- Tuberculosis Treatment (ATT) and immunosuppressive drugs, such as Tacrolimus (TAC). This study aimed to assess this interaction and discuss the guidelines used in this specific case. Methods: A retrospective, observational, single-center analysis was performed at the Department of Clinical Pharmacology (National Centre of Pharmacovigilance, Tunisia). We analyzed the database of patients who received TAC from 2009 until 2018. We included samples provided from renal transplant patients infected by Mycobacterium tuberculosis after transplantation. Trough blood levels (C0) were determined using an immunoassay analyzer. The Therapeutic Range (TR) of TAC was considered between 5 and 10 ng/mL. Pharmacokinetic parameters were compared between the period of co-administration of TAC/ATT (period A) and the period during which patients received only TAC (period B). Results: Seven renal transplant patients treated by TAC were included. 41 samples were analyzed (16; period A, 25; period B). Only 6 % of C0 values were found within TR during period A, while this rate was 44% during period B. During period A, 88% of TAC C0 was under the lower limit of TR, indicating a high risk of transplant rejection. The mean C0 and C0/D were significantly lower during period A (3.11±1.53 ng/mL vs 7.11 ± 3.37 ng/mL; p = 0.001 and 33.06 ± 24.89 vs 83.14 ± 44.46; p = 0.0006, respectively), without difference in doses between periods. Conclusion: Considering the results of this study, clinicians are suggested to monitor TAC closely in this particular circumstance.

Background: Lactoferrin (LF) is a member of the transferrin family, which is known for its immunomodulatory properties. LF has been widely used as an anticancer medication in various cancers including breast cancer. Aims: The current study aimed to examine the molecular mechanisms underlying the therapeutic potential of recombinant human lactoferrin (rhLF), either alone or combined with epirubicin (EPI), in mice bearing solid Ehrlich carcinoma (SEC). Methods: SEC-bearing female mice (n=40) were divided into 4 equal groups. Mice were given rhLF orally (100mg/kg/mouse) daily and/or EPI i.p (8mg/kg/mouse). The experiment lasted 14 days, after which samples were collected to measure IL-18 and phosphorylated c-Jun N-terminal kinase (p-JNK) by ELISA and p⁵³gene expression by real-time PCR. Results: Administration of rhLF, either alone or combined with EPI, markedly decreased the tumor volume and increased tumor inhibition rate as well as survival rate compared to either tumor control group or EPI-mono treated group. In addition, co-administration of rhLF and EPI increased the level of activated JNKs and expression of p⁵³in tumor tissues compared to the tumor, control group, exhibiting their pro-apoptotic properties. Moreover, the combined treatment with rhLF and EPI elevated IL-18 level in the intestinal mucosa compared to other experimental groups with a possible immune-enhancing effect. Conclusion: Recombinant human lactoferrin exhibited potential anticancer and immune-enhancing properties in mice with breast cancer. Co-treatment with rhLF and EPI proved to be a promising strategy in cancer treatment.

Objective: The purpose of this study was to investigate renal function in patients with brucellosis before and at the end of gentamicin therapy. To ensure the safety of therapeutic doses of gentamicin, renal functions in brucellosis patients were monitored regarding drug serum levels and check for early detection biomarkers of nephrotoxicity. Methods: In this cross-sectional study, 41 patients (25 men and 16 women, aged over 15 years) were included, with confirmed acute brucellosis that referred to Brucellosis Research Center in Hamadan, west of Iran between March 2018 to February 2019. At baseline before treatment (first step) and 7 days after gentamicin administration (second step), serum uric acid, blood urea nitrogen (BUN), serum and urine creatinine, erythrocyte sedimentation rate (ESR), quantitative C-reactive protein (CRP) and urinary β2-microglobulin (β2M) were measured. Gentamycin serum level due to the highest risk of nephrotoxicity with this drug in aminoglycoside class was also checked by HPLC method. The data were analyzed using SPSS version 22. Results: The mean urinary β 2M level, serum and urinary creatinine, uric acid, BUN, and quantitative CRP levels in the first step and second step, there were no statistical differences between the two steps. There was a correlation between urinary creatinine and ESR. In addition, a positive correlation was found between urinary β2M and serum gentamicin level. ESR levels have been significantly reduced in the patients after the treatment compared to before it. Conclusion: Our findings confirm that gentamicin is safe at the dose of 5 mg/kg/day for one week intravenously in brucellosis patients.

Background: An invasive dental procedure is considered one of the risk factors for osteonecrosis of the jaw, especially among patients on bisphosphonates. This study aimed to determine the awareness and perceptions of medical practitioners regarding bisphosphonate-related osteonecrosis of the jaw (BRONJ), and their attitude towards dental referrals of such patients. Methods: This cross-sectional questionnaire-based study was conducted among medical practitioners in and around Mysore city, Karnataka, India, who commonly prescribe bisphosphonates. The sample included orthopaedic doctors, physicians, endocrinologists, and oncologists, divided based on the duration of practice and speciality. Data on the type of practice, awareness of BRONJ, referral to a dentist before/during therapy, and patient education about adverse effects, were collected and analyzed. A p-value ≤0.05 was considered statistically significant. Results: Among 58 practitioners, 84.5% (49) were aware of the association between bisphosphonates and BRONJ, while 56.9% (33/58) believed dental procedure to be a risk factor, and 55.2% (32/58) did not recommend screening of the oral cavity by a dentist before initiation of bisphosphonate therapy. A majority (65.5%) of them educated their patients about adverse effects. Mean knowledge scores varied with specialization (post-graduation vs. super specialization = 1.43 vs. 2; p = 0.01) but not with the duration of practice (<= 10 years vs. >10 years= 1.57 vs. 1.4; p= 0.24). Conclusion: The practitioners in our study were oblivious to dental procedures' role in the osteonecrosis of the jaw, highlighting the need for continuing education programs regarding BRONJ for medical and dental professionals. Clinicians updated regarding evidence-based practices and working cooperatively in teams may reduce the incidence of medication-related osteonecrosis of the jaw.

Background: Evidence broadly identifying medications newly-initiated prior to the occurrence of a urinary tract infection (UTI) in patients with diabetes, heart failure, or both of these conditions is lacking. Objective: The aim was to broadly assess medication filling patterns and incidence of UTIs to identify medications or medication classes most frequently initiated prior to UTI occurrence. Methods: This retrospective study utilizing a national claims database examined medications commonly initiated in the six months preceding a UTI in patients with diabetes and/or heart failure. Patients with a new diagnosis of UTI, a diagnosis of diabetes and/or heart failure, continuous enrollment in the database for at least 12 months prior to the index UTI occurrence, and who initiated at least one new medication in the 6 months preceding the index UTI were evaluated. Results: 12,744 patients met criteria: 10,626 (83.4%) had a diagnosis of diabetes, 838 (6.6%) had a diagnosis of heart failure, and 1,280 (10.0%) had diagnoses for both. Opioids were the most commonly filled medication class among all three groups. Medications from the SGLT2i class were the twelfth, eleventh, and eighteenth most common medications filled prior to the index UTI for all patients, patients with diabetes, and patients with diabetes and heart failure, respectively. Conclusion: Opioids were by far the most commonly initiated medication class in the 6 months prior to UTI incidence in patients with diabetes and/or heart failure. SGLT2i medications were not commonly initiated in the 6 months prior to the occurrence of a UTI.

Background: Crohn Disease (CD) is an intestinal inflammatory condition characterized by a complex pathogenesis, with elevated levels of inflammatory cytokines. Adalimumab and certolizumab are two biologic drugs inhibiting TNF-α. Objective: We report the first case of a probable relationship, according to Naranjo causality assessment score, between two consecutive treatments with TNF-α inhibitors and induced erectile dysfunction (ED), that disappeared after switching to another biologic drug (ustekinumab). Case Presentation: This case report describes a possible and important association of two TNF-α inhibitors (certolizumab and adalimumab) and ED in a male patient with CD, with resolution after switching to Ustekinumab (anti-interleukin 12 and 23 biologic drug). A 65 years old man experienced erectile dysfunction during treatment with an anti-TNF. The adverse effect disappeared after discontinuation of the drug. All necessary urologic exams were carried out. Adalimumab was replaced by certolizumab and sexual disfunction symptoms appeared again, improving typically at the end of treatment periods and getting worse with each new dose. Results: Switching to ustekinumab lead to a resolution of the erectile dysfunction. Conclusion: We describe for the first time a sexual dysfunction possibly due to two similar anti TNF drugs and its resolution after the switch to another similar but different drug, highlighting the potential difference between biologic drugs.

Introduction: Bullous pemphigoid is the most common chronic recurrent autoimmune subepidermal blistering disorder most prevalent in the geriatric population. It varies widely in clinical presentation ranging from tense bullae to intense generalized pruritus. It is immunologic in origin with the presence of IgG antibodies. Case Report: A 47-year-old female presented to the hospital with complaints of blisters in the lower limbs, which she self managed with neem oil, after which the blisters occurred over the body. The patient also experienced blisters over both upper and lower limbs, gluteal region, painful generalized ulcers, necrotic patches, multiple erythematous blisters, ulcer erosions over bilateral legs and upper limbs with few lesions, which were foul-smelling and oozing. On the second day of admission, the patient’s CRP and ESR levels were tested and the levels were 33.5 and 35 mm/hr, respectively. The patient was treated with an injection of meropenem 1 g three times daily, dexamethasone 4 mg once daily, and ofloxacin 400 mg once daily. On the third day of admission, the patient complained of leg swelling, and subsequently, D-Dimer levels were checked, which showed a value of 5,740 and was treated with an injection of enoxaparin 40 mg for the same throughout the course of the hospital stay A skin biopsy confirmed the diagnosis of bullous pemphigoid. The culture test showed the growth of Klebsiella pneumonia and Acinetobacter baumani, which were resistant to most of the antibiotics. The patient was managed appropriately with modalities including antibiotics, anti-inflammatory agents, immunosuppressants, multivitamins, fluids, and albumin. The patient responded well to the treatment without new lesions or fever spikes. There was the presence of necrotic patches of old lesions alone at the time of discharge. Conclusion: This case report was done with the purpose of presenting an exemplary case of bullous pemphigoid aggravated by the application of neem oil and emphasizing the inappropriate use of folk medicine in an autoimmune disease like bullous pemphigoid.

Background: Caplan's syndrome, also known as rheumatoid pneumoconiosis (RP), is a rare disease associating pneumoconiosis with rheumatoid arthritis (RA). This is one of the rare cases evaluating the effect of Rituximab, which was used initially for the treatment of RA, on pneumoconiosis Case Presentation: In this case report, we described a 21-year long-standing history of pneumoconiosis and its association with RA. A 67-year-old man diagnosed with pneumoconiosis presented with morning stiffness and symmetrical polyarthritis. Laboratory investigations showed high titers of rheumatoid factor (RF) and anti-citrullinated protein antibodies. The diagnosis of RA was established and the patient was put on leflunomide. Then, he was treated with Rituximab, as he did not respond to leflunomide. The patient showed marked improvement as pain and swelling decreased. More importantly, Caplan’s nodules stabilized on chest-computed tomography. Conclusion: The use of rituximab in pneumoconiosis does not alter the evolution of the pulmonary nodules. More trials are needed to establish a treatment consensus for RP.

Introduction: Flagellate erythema is a distinctive morphologic reaction pattern recognized by whiplash-like pruritic erythematous eruption. It is usually encountered in patients receiving bleomycin. Only one case of docetaxel-induced flagellate erythema is reported in the literature. Case Report: Herein, we report a rare case of docetaxel-induced flagellate erythema in a 53 years old woman with no particular medical history treated with docetaxel for metastatic adenocarcinoma of her right breast. Seven days after the third course, she developed multiple lineal and parallel pruritic erythematous streaks mainly on her chest and abdomen. The cutaneous erythema disappeared gradually over 10 days, leaving hyper-pigmented post-inflammatory linear scars lasting two weeks. The same reaction reappeared after the fourth and the fifth docetaxel course. Conclusion: Flagellate erythema has been reported as an adverse drug reaction secondary to several antineoplastic molecules, including docetaxel. Further studies are needed to discover its underlying mechanisms in order to figure out better treatment plans and prevention.

Background: Dextromethorphan, an N-methyl-d-aspartate receptor antagonist, has been used as cold and cough medication. Serious adverse events with therapeutic doses of dextromethorphan are rarely observed. Here, we report three cases of altered levels of consciousness in children with a therapeutic dose of dextromethorphan. Case Presentation: In all three cases, children developed an altered level of consciousness after taking the first dose of syrup dextromethorphan. Children were unresponsive to any verbal command and pain stimuli. Medical history revealed no pre-existing comorbidities. Other systemic, cardiovascular, abdominal, respiratory and nervous system examinations were normal. All patients were hospitalised and managed with symptomatic and supportive care. Dextromethorphan was stopped. After adequate treatment, all of them recovered satisfactorily. The causality assessment was done based on the World Health Organization Uppsala Monitoring Centre causality scale, and it was probable/likely in all three cases. Conclusion: In children, an altered level of consciousness could occur with therapeutic doses of dextromethorphan; hence, health care professionals should prescribe dextromethorphan with extreme caution.

Purpose: The simultaneous occurrence of cerebral toxoplasmosis and cryptococcosis is rare. The infections continue to be treated with sulfadiazine and amphotericin-B-based regimens (preferred therapy), respectively. Both these drugs are linked to some serious adverse drug reactions (ADRs). We report such a unique instance of both; the CNS co-infections and adverse drug reactions to the preferred therapy. Case Presentation: A 44-year-old Asian-Indian female was diagnosed with cerebral toxoplasmosis, impending cryptococcal meningoencephalitis, and acquired immune deficiency syndrome (AIDS). The preferred therapy of opportunistic CNS co-infections commenced. Within a week, she had an occurrence of fall in hemoglobin concentrations (11.3 g/dL to 5.6 g/dL; grade IV), reticulocytosis (1% to 3.2%), and indirect hyperbilirubinemia (0.5 mg/dL to 2.8 mg/dL; grade IV) after sulfadiazine administration. The drug was discontinued and the patient was treated with hematocrit transfusions. After amphotericin-B deoxycholate (AmBd) administration, the patient developed hypokalemia (serum potassium; 4.5 mmol/L to 2.7 mmol/L) and increased serum creatinine (1.0 to 2.2 mg/dL; stage-I) levels. Hence, AmBd was discontinued and potassium correction was given. The patient got diagnosed with sulfadiazine induced hemolytic anemia and AmBd induced acute renal failure. He was switched to alternative therapy regimens for the treatment of cerebral toxoplasmosis and cryptococcosis. Radiological investigations were followed up to confirm the clinical outcomes of alternative therapy. Complete recovery from the ADRs and opportunistic infections was observed. Conclusion: The preferred therapy regimens for toxoplasmosis and cryptococcosis are accompanied by potential adverse drug reactions, thus continuous monitoring is vital, especially in the initial phases of therapy. Discontinuation of the treatment should be the preliminary intervention in the management. Having said that, alternative therapy regimens had an optimal clinical response in the present case.

Background: Losing-salt tubulopathies, such as Bartter syndrome, are rare and usually inherited due to mutations of tubular reabsorption channels of the nephrons. Despite its scarcity, some cases of acquired losing-salt tubulopathies have been described. In this case report, we discuss the main aspects of Bartter syndrome and present a rare pediatric case of probable tacrolimusinduced Bartter-like syndrome in a renal transplanted boy. Case Presentation: A ten-year-old male patient with end-stage renal disease due to endo and extra capillary glomerulonephritis was submitted to renal transplantation from a deceased donor. The post-operatory evolution was satisfactory with normalization of serum creatinine levels, mild hypertension, and the absence of metabolic disorders. The immunosuppression protocol included tacrolimus (0.3 mg/kg/day), mycophenolate (455 mg/m²/day) and prednisone (0.5 mg/kg/day). Two months later, the patient was hospitalized due to vomiting, dehydration, intense hypokalemia (1.3 mEq/L), hyponatremia (125 mEq/L), and hypochloremia (84 mmol/L). During hospitalization, he evolved with polydipsia (3000 mL/day) and polyuria (120-160 mL/m2/h) associated with major elevation of urinary potassium excretion, hypercalciuria, mild metabolic alkalosis, hyperfiltration, and proteinuria. The tacrolimus dose was reduced under the suspicion of tubular dysfunction, leading to a better metabolic profile. However, the patient developed a Banff IIb graft rejection, which required pulse therapy and elevation of tacrolimus and mycophenolate doses. Recovery of renal function parameters occurred, but the metabolic disorders worsened following tacrolimus dose elevation. The patient required chronic potassium, chloride, and sodium replacement. Conclusion: After administering immunosuppressive medications, physicians should be aware of the possibility of Bartter-like or other losing-salt tubulopathies syndromes that can affect metabolic homeostasis. The suspicion must always be considered in the case of a transplanted patient who presents dehydration and hydroelectrolytic disorders right after the commencement of nephrotoxic immunosuppressive drugs, including tacrolimus and cyclosporine.