Possible association between toxic epidermal necrolysis and ciprofloxacin

Ciprofloxacin-induced cutaneous adverse drug events: a systematic review of descriptive studies

OBJECTIVES

Ciprofloxacin (CIPRO) is a fluroquinolone class antibiotic used commonly for the treatment of various acute and chronic bacterial infections. However, recently there is increase in the case reports of CIPRO-induced Cutaneous Adverse Drug Reactions (CADRs). We aim to systematically review all the descriptive studies of CIPRO induced CADRs.

METHODS

Medline (via PubMed) was searched without any language or date restriction from inception to March 2019 using search terms of "Ciprofloxacin" and "Cutaneous reactions." We included only the descriptive studies, which elucidate the CADRs experienced by the patients following the administration of CIPRO. Two reviewers involved in study selection, data extraction and quality assessment of the included studies. Discrepancies were resolved by consensus between the reviewers.

RESULTS

Thirty-nine studies (out of 446) were found to be eligible for the final inclusion. The dose of CIPRO among the included studies was ranging from 500 to 1,000 mg/day and duration of treatment was between 7 and 10 days. The most common CADRs observed were toxic epidermal necrolysis, Stevens-Johnson syndrome, fixed drug eruptions, bullous fixed drug reaction, acute generalized pustulosis, erythema multiforme, drug rash with eosinophilia and systemic symptoms and erythema nodosum.

CONCLUSIONS

Management of the CIPRO-induced CADRs is recommended with the complete cessation of the CIPRO, followed by supportive management with oral or topical glucocorticoids, emollients, and topical moisturizers. CIPRO is likely to cause CADRs, physicians should be vigilant while prescribing it to the patients.

Norfloxacin-Induced Toxic Epidermal Necrolysis

OBJECTIVE:

To report a case of toxic epidermal necrolysis (TEN) in a man who was treated with oral norfloxacin for prostatitis.

CASE SUMMARY:

A 40-year-old man presented with a severe skin reaction, which was diagnosed as TEN. He had received norfloxacin 800 mg/day over a 14-day period for prostatitis and, 10 days after finishing the treatment regimen, he developed cutaneous and mucous lesions typical of TEN. After a prolonged hospitalization and treatment with oral prednisolone therapy, fluid resuscitation, and wound dressing, the man recovered.

DISCUSSION:

TEN is an infrequent, yet often fatal, severe systemic and cutaneous disease that is most often an adverse drug reaction. There are few case reports of TEN induced by fluoroquinolones. A MEDLINE search (1966–February 2005) revealed no reports of toxic epidermal necrolysis, but one incidence of Stevens—Johnson syndrome due to norfloxacin therapy. An objective causality assessment suggests that TEN was probably related to norfloxacin in this patient.

CONCLUSIONS:

To our knowledge, this is the first case of TEN associated with the use of oral norfloxacin. We hope that this case report creates awareness that norfloxacin-induced TEN is possible.

Stevens-Johnson syndrome associated with ciprofloxacin: a review of adverse cutaneous events reported in Sweden as associated with this drug

Stevens-Johnson syndrome is a severe mucocutaneous reaction, which can be elicited by various drugs. We present 2 cases with this syndrome associated with ciprofloxacin treatment and review the adverse cutaneous events reported as possibly related to ciprofloxacin treatment in Sweden between 1988 and 2000. Eight cases, excluding ours, of Stevens-Johnson syndrome, toxic epidermal necrolysis, and erythema multiforme were reported. This implies an annual incidence of these adverse cutaneous events of 0.045 per 100,000 treated patients (assuming an average treatment length of 10 days). One patient died, but ciprofloxacin was not considered to be the major cause of death. Together with previous data from the literature, our report supports the view that ciprofloxacin can cause severe adverse cutaneous events.

Quinolone hypersensitivity

PURPOSE OF REVIEW

Quinolones are potent antibacterial agents that can cause drug hypersensitivity reactions affecting different organs. A better understanding of the underlying mechanism and the level of crossreactivity within different quinolones is needed to handle and prevent these diseases.

RECENT FINDINGS

The adverse side-effects caused by quinolones are the result of different immunological mechanisms and cause quite different diseases. The development of an assay detecting quinolone-specific IgE revealed specific antibodies in more than 50% of patients with immediate-type reactions, and the majority of sera also reacted with related compounds. In maculopapular drug exanthemas caused by ciprofloxacin, specific T cells could be detected and cloned. They reacted with ciprofloxacin directly, and crossreactivity to related compounds was detected in approximately 50% of the clones.

SUMMARY

Quinolones can cause drug hypersensitivity reactions by different immunological mechanisms. In-vitro analysis suggests that crossreactivity is common.

Recurrent fatal drug-induced toxic epidermal necrolysis (Lyell's syndrome) after putative beta-lactam cross-reactivity: Case report and scrutiny of antibiotic imputability

OBJECTIVE

A series of antibiotics may be responsible for toxic epidermal necrolysis. We report two successive episodes of toxic epidermal necrolysis in the same patient. Drug imputability criteria designate a cross-reactivity between two antibiotics of different chemical classes but sharing the beta-lactam ring in common.

DESIGN

Descriptive case report and review of the literature.

SETTING

Medical intensive care unit in a university medical center. PATIENT AND MAIN RESULTS: A 75-yr-old woman developed a first episode of toxic epidermal necrolysis (involving 40% of the body surface) after intake of cefotaxime, a third-generation cephalosporin. Perfusions of high-dose immunoglobulins rapidly improved the lesions, followed by partial reepithelialization in 5 days. Sepsis required the administration of meropenem, which is a carbapenem antibiotic. The epidermal destruction immediately recurred, with extension to previously uninvolved skin areas and fatal consequences.

CONCLUSIONS

The beta-lactam ring present in cephalosporins and carbapenems represents the putative chemical structure responsible for the presently reported cross-reactivity to two antibiotics of different classes. Drugs having any chemical similarity to the initial culprit compound should be strictly avoided when possible in the management of toxic epidermal necrolysis.

Ofloxacin: a probable cause of toxic epidermal necrolysis

OBJECTIVE

To report a fatal case of toxic epidermal necrolysis in a man who was treated with oral ofloxacin for epididymitis.

CASE SUMMARY

A 75-year-old white man received 23.6 grams of ofloxacin over a 51-day period for epididymitis. He experienced a severe skin reaction diagnosed as toxic epidermal necrolysis. The man died from complications related to toxic epidermal necrolysis.

DISCUSSION

Toxic epidermal necrolysis is an infrequent, yet often fatal, severe, systemic, cutaneous disease most often the result of an adverse drug reaction. Fluoroquinolones have rarely been implicated in cases of toxic epidermal necrolysis. A MEDLINE search from 1966 to December 2000 revealed no reports of toxic epidermal necrolysis, erythema multiforme, or Stevens-Johnson syndrome due to ofloxacin therapy. However, a large case-control study included three cases of either Stevens-Johnson syndrome or toxic epidermal necrolysis associated with ofloxacin use, but no details of the cases were given. This report rules out other causes of toxic epidermal necrolysis and implicates ofloxacin in what appears to be an atypical presentation of drug-induced toxic epidermal necrolysis.

CONCLUSIONS

There is very little published information regarding ofloxacin-induced toxic epidermal necrolysis. There are a few case reports of other fluoroquinolones that have been associated with toxic epidermal necrolysis. It is hoped that this case report creates awareness that ofloxacin-induced toxic epidermal necrolysis is possible.

Ciprofloxacin-induced toxic epidermal necrolysis

OBJECTIVE

To report a case of probable ciprofloxacin-induced toxic epidermal necrolysis (TEN) in an adult with systemic lupus erythematosus (SLE).

CASE SUMMARY

A 31-year-old woman with SLE developed a pruritic rash following her first dose of oral ciprofloxacin. She continued taking ciprofloxacin, and the rash progressively worsened, becoming painful and covering her entire body. She discontinued the ciprofloxacin six days later and presented to the hospital, where two days later, her rash began to desquamate with epidermal erosions and a positive Nikolsky's sign. Skin biopsy was positive for TEN. She then was transferred to a burn-treatment unit because of the severity of the skin involvement. The patient recovered following prolonged hospitalization and rehabilitation.

CONCLUSIONS

Although TEN occurs rarely with ciprofloxacin, extensive postmarketing surveillance needs to be performed to determine other risk factors for its development and to establish the incidence of TEN and other severe cutaneous reactions caused by ciprofloxacin or the other fluoroquinolones.