Immune-mediated reactions to vancomycin: A systematic case review and analysis

BACKGROUND

Vancomycin is a broad-spectrum antibiotic whose use may be limited by adverse drug reactions (ADRs). Although vancomycin toxic effects are known, there are limited data on vancomycin hypersensitivity reactions (HSRs).

OBJECTIVE

To understand the most commonly reported vancomycin HSRs through systematic case review.

METHODS

We performed a literature search for English-language case reports and series from 1982 through 2015 (last search July 31, 2015) on Ovid MEDLINE and PubMed. The search included the subject heading vancomycin with the subheading adverse effects and separate text searches for vancomycin with a list of specified HSRs. References of identified articles were reviewed to find additional articles. Clinical data were collected and summarized.

RESULTS

Of 201 identified articles, 84 were screened and 57 fully assessed; these 57 articles contained 71 vancomycin HSR cases that were included in analysis. Vancomycin HSRs were immediate (anaphylaxis, n = 7) and nonimmediate (n = 64). Nonimmediate HSRs included linear IgA bullous dermatosis (LABD, n = 34), drug rash eosinophilia and systemic symptoms (DRESS) syndrome (n = 16), acute interstitial nephritis (AIN, n = 8), and Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN, n = 6). Median times of vancomycin therapy before HSR onset was 7 days (interquartile range [IQR], 4-10 days) for LABD, 9 days (IQR, 9-22 days) for SJS/TEN, 21 days (IQR, 17-28 days) for DRESS syndrome, and 26 days (IQR, 7-29 days) for AIN. Overall, 11 patients (16%) died, and 4 (6%) had deaths attributed to the HSR.

CONCLUSION

Vancomycin causes a variety of HSRs; the most commonly identified were nonimmediate HSRs, with LABD being most frequent. We observed a high frequency of HSR mortality. Further data are needed to understand the frequency and severity of vancomycin HSRs.

Diffuse Interstitial Pulmonary Infiltrates in Malignant Melanoma

Only a few cases of sarcoidosis-like reaction to a pharmacologic compound have been reported in patients with melanoma in the literature. Long-term treatment with interferon alpha may be assumed. We report a case of a 25-y-old man who presented to our department with diffuse interstitial pulmonary infiltrates and slightly enlarged mediastinal lymph nodes as determined by computed tomography. He had a history of malignant melanoma with 18 months of interferon alpha-2 therapy. Histological analysis of a transbronchial biopsy revealed sarcoidosis-like reactions.

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