Question

A child treated for meningitis develops right hypochondrial abdominal pain and jaundice. Which drug is the most likely cause?

• A. Vancomycin
• B. Amikacin
• C. Ceftriaxone
• D. Meropenem

Hint:

Ceftriaxone Adverse Effect Pearl: High-dose ceftriaxone causes biliary pseudolithiasis sludging due to calcium-ceftriaxone complex precipitation. Spontaneously resolves after stopping therapy!

Answer 1

The Correct Option is C

Concept:
Ceftriaxone is a broad-spectrum, third-generation cephalosporin commonly utilized at high doses ($100\text{ mg/kg/day}$) in pediatric bacterial meningitis due to its excellent cerebrospinal fluid penetration.
A well-documented adverse effect associated with high-dose or prolonged ceftriaxone therapy is the formation of biliary sludge and pseudolithiasis.
Explanation:
• Ceftriaxone has a dual elimination pathway, with approximately $40\%$ excreted unchanged into the bile where it reaches high concentrations.

• In the gallbladder, ceftriaxone anions bind with divalent calcium ions ($Ca^{2+}$) to form an insoluble, radio-opaque precipitate of calcium-ceftriaxone salt.

• This precipitates clinically as biliary pseudolithiasis (biliary sludging or reversible gallstones), occurring in up to $15$--$40\%$ of children receiving high-dose regimens.

• Affected children can present with symptoms mimicking acute cholecystitis, including right upper quadrant (hypochondrial) pain, vomiting, nausea, and obstructive jaundice.

• Unlike true cholesterol or pigment stones, ceftriaxone-induced pseudolithiasis is completely reversible and spontaneously resolves within several days to weeks after discontinuing the drug.

• Vancomycin and amikacin are nephrotoxic and ototoxic, while meropenem rarely induces biliary sludging.
Final Answer:
Ceftriaxone is the drug responsible for calcium-ceftriaxone biliary precipitation, causing biliary pseudolithiasis, right hypochondrial pain, and jaundice.