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Almasoudi AA, Bablghaith ES, Alaauldeen SI, M Falemban A, Sherbeeni AA, Bulkhi AA. Ceftriaxone-induced leukocytoclastic vasculitis: a case report and literature review of antibiotic-induced leukocytoclastic vasculitis. J Int Med Res 2022; 50:3000605221097768. [PMID: 35587703 PMCID: PMC9127858 DOI: 10.1177/03000605221097768] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Leukocytoclastic vasculitis (hypersensitivity vasculitis) is defined as small blood vessel inflammation with skin or other systemic manifestations due to infections, drugs, or neoplastic disease. This clinical case report highlights an association between ceftriaxone and leukocytoclastic vasculitis in a 49-year-old female patient with a history of penicillin allergy, on mirtazapine for anxiety disorder. Articles concerning antibiotic-induced leukocytoclastic vasculitis are also reviewed. The patient reported a symptom of upper respiratory tract infection and fever 5 days previously for which she received ceftriaxone for 2 days before presenting to the emergency department with a pruritic skin rash in the upper and lower extremities and swollen lips for 1 day. The rash was erythematous, maculopapular, itchy, and non-tender, with no mucus membrane involvement. Laboratory investigations revealed leukocytosis (white blood cells, 22.3 × 109/L) that was mainly eosinophilic (18.4%). The patient was administered prednisolone and antihistamine after stopping ceftriaxone empirically. A skin biopsy confirmed the diagnosis of leukocytoclastic vasculitis. Significant clinical improvement was observed after treatment initiation. Upon follow-up, the skin rash was resolved entirely with no scars; however, there was skin-peeling over the lower extremities. Recognition of antibiotic-induced leukocytoclastic vasculitis is crucial as many classes of antibiotics can contribute to this condition. Continuation of the offending drug may lead to life-threatening complications.
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Affiliation(s)
- Aseel A Almasoudi
- Department of Internal Medicine, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Eman S Bablghaith
- Department of Internal Medicine, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Samaher I Alaauldeen
- Department of Internal Medicine, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Ayman M Falemban
- Department of Internal Medicine, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Ahlam A Sherbeeni
- Department of Internal Medicine, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Adeeb A Bulkhi
- Department of Internal Medicine, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia.,Department of Internal Medicine, College of Medicine, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia
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The Many Faces of Purpura: Vancomycin-Induced Leukocytoclastic Vasculitis. Case Rep Infect Dis 2021; 2021:9932425. [PMID: 34194855 PMCID: PMC8203330 DOI: 10.1155/2021/9932425] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 05/21/2021] [Indexed: 01/17/2023] Open
Abstract
Leukocytoclastic vasculitis is a rare form of immune-mediated vasculitis that might be caused by infections or autoimmune diseases or might be precipitated by specific medications. We describe a 65-year-old patient, who was receiving vancomycin for a methicillin-sensitive Staphylococcus aureus permacath infection. Vancomycin was chosen due to medication non-adherence and the patient's desire to receive antimicrobial therapy in conjunction with his scheduled dialysis sessions. The patient's medical history was notable for untreated hepatitis C infection and end-stage renal disease, requiring hemodialysis three times a week. Vancomycin was administered during dialysis sessions. After one week of therapy, the patient developed bilateral lower extremity purpura. Skin biopsy was suggestive of leukocytoclastic vasculitis with an absence of intravascular thrombi. Serum cryoglobulins were negative, making cryoglobulinemia due to HCV infection unlikely. Following cessation of vancomycin therapy, the rash gradually disappeared with scarring in the form of post-purpuric hyperpigmentation. Despite its widespread use, vancomycin is a rare cause of leukocytoclastic vasculitis. Clinicians should keep in mind a wide range of differential diagnosis of bilateral lower extremity purpura as treatment differs depending on its underlying etiology.
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Commonly used intracameral antibiotics for endophthalmitis prophylaxis: A literature review. Surv Ophthalmol 2020; 66:98-108. [PMID: 32343980 DOI: 10.1016/j.survophthal.2020.04.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 04/12/2020] [Accepted: 04/13/2020] [Indexed: 01/25/2023]
Abstract
Endophthalmitis is a serious complication of cataract surgery that occurs in thousands of patients each year. To decrease the incidence of postoperative endophthalmitis, many surgeons inject intracameral antibiotics (cefuroxime, moxifloxacin, and vancomycin) routinely at the end of surgery. A large number of recently published retrospective studies and large database analyses have reported decreased endophthalmitis rates with routine antibiotic use, and the only prospective, multicenter, randomized trial performed by the European Society of Cataract and Refractive Surgery demonstrated that intracameral cefuroxime decreases the incidence of postoperative endophthalmitis. Routine cefuroxime use has become common in many European countries, whereas moxifloxacin is the most commonly used drug in India, and vancomycin use predominates in Australia. The decision regarding whether or not to use intracameral prophylaxis and the drug that is selected varies considerably throughout the world because of antibiotic availability and cost, and the spectrum of causative organisms. Adverse events due to intracameral antibiotics are infrequent, but complications such as hemorrhagic occlusive retinal vasculitis have been reported. Because additional prospective, comparative trials have not been performed, a consensus regarding best practices to prevent postoperative endophthalmitis has not been reached. Additionally, many surgeons do not routinely use intracameral antibiotics because they believe them unnecessary with modern aseptic techniques, small incision surgery, and shorter operating times. We discuss the most commonly used intracameral antibiotics, present the risks and potential benefits of this approach, and highlight challenges with drug compounding and safety.
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Sharma P, Sharma E, Neupane SP, Dahal S, Dahal S. Vancomycin-Induced Leukocytoclastic Vasculitis: A Rare Case Report. J Investig Med High Impact Case Rep 2018; 6:2324709618820873. [PMID: 30622993 PMCID: PMC6304699 DOI: 10.1177/2324709618820873] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 11/28/2018] [Accepted: 12/02/2018] [Indexed: 11/16/2022] Open
Abstract
Vancomycin causes different types of hypersensitivity reactions, ranging from
localized skin reactions to generalized cardiovascular collapse. However, cases
of vancomycin-induced leukocytoclastic vasculitis are rare. In this article, we
present a case where the patient developed palpable purpura on his bilateral
lower limbs following treatment with vancomycin. He was diagnosed with
vancomycin-induced leukocytoclastic vasculitis that resolved without sequelae
after withdrawal of vancomycin.
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Affiliation(s)
| | | | - Sanjay P Neupane
- New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY, USA
| | - Suyash Dahal
- KIST Medical College and Teaching Hospital, Lalitpur, Nepal
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Pingili CS, Okon EE. Vancomycin-Induced Leukocytoclastic Vasculitis and Acute Renal Failure Due to Tubulointerstitial Nephritis. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:1024-1027. [PMID: 28943633 PMCID: PMC5627863 DOI: 10.12659/ajcr.905214] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and sepsis are commonly treated with intravenous vancomycin. However, vancomycin treatment is associated adverse reactions, including skin rashes and nephrotoxicity. We present a case of acute renal failure due to acute tubulointerstitial nephritis associated with a diffuse leukocytoclastic vasculitic skin eruption following intravenous vancomycin treatment. CASE REPORT A 79-year-old Caucasian male patient was treated with intravenous vancomycin for MRSA bacteremia. Prior to treatment, his creatinine was normal at 0.6 mg/dl. He presented one week later with shortness of breath, lower limb edema, and acute renal failure. He had a diffuse maculopapular rash involving the trunk and both upper and lower extremities. A renal biopsy and left arm skin biopsy were examined histologically. The skin biopsy showed leukocytoclastic vasculitis. Renal biopsy showed some sclerosed glomeruli, some with mesangial proliferation, and tubulointerstitial inflammation with eosinophils and plasma cells and mild interstitial fibrosis. Although there was some renal arteriolosclerosis, no vasculitic changes were seen, and no vascular thrombosis was present. A diagnosis of leukocytoclastic vasculitis and acute tubulointerstitial nephritis secondary to intravenous vancomycin therapy was made. CONCLUSIONS Although skin reactions associated with drug therapy are common, vancomycin-associated dermal vasculitis is rare. Tubulointerstitial nephritis is also a rare association with vancomycin treatment. This case report has highlighted that patients being treated with intravenous vancomycin should be carefully observed for acute skin rashes and deterioration in renal function, which can be managed by ceasing treatment with vancomycin, steroid challenge, and preventing future exposure to similar antimicrobial agents.
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Affiliation(s)
- Chandra Shekar Pingili
- Department of Infectious Diseases, Prevea Health, Sacred Heart Hospital, Eau Claire, WI, USA.,Prevea Health, Eau Claire, WI, USA.,Sacred Heart Hospital, Eau Claire, WI, USA
| | - Emmanuel E Okon
- Department of Infectious Diseases, Marshfield Clinic, Sacred Heart Hospital, Eau Claire, WI, USA.,Sacred Heart Hospital, Eau Claire, WI, USA.,Marshfield Clinic, Eau Claire, WI, USA
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Mawson AR, Eriator I, Karre S. Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN): could retinoids play a causative role? Med Sci Monit 2015; 21:133-43. [PMID: 25579087 PMCID: PMC4301467 DOI: 10.12659/msm.891043] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN) are overlapping manifestations on a spectrum of acute drug-induced conditions associated with severe blistering, skin peeling, and multi-organ damage. TEN is an eruption resembling severe scalding, with ≥30% skin detachment. SJS is a mild form of TEN, characterized histologically by epidermal keratinocyte apoptosis with dermo-epidermal separation and extensive small blisters with <10% body surface skin detachment. The syndrome can be induced by numerous medications and typically occurs 1–4 weeks after the initiation of therapy. Granulysin is found in the lesions of patients with SJS/TEN and plays a significant pathogenic role in the condition, but the overall mechanisms linking medications, granulysin, and disease manifestations remain obscure. This paper reviews evidence suggesting that the different medications implicated in SJS/TEN have the common property of interacting and synergizing with endogenous retinoids (vitamin A and its congeners), in many instances causing the latter to accumulate in and damage the liver, the main storage organ for vitamin A. It is hypothesized that liver damage leads to the spillage of toxic retinoid compounds into the circulation, resulting in an endogenous form of hypervitaminosis A and cytotoxicity with widespread apoptosis, mediated by granulysin and recognized as SJS/TEN. Subject to testing, the model suggests that symptom worsening could be arrested at onset by lowering the concentration of circulating retinoids and/or granulysin via phlebotomy or plasmapheresis or by pharmacological measures to limit their expression.
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Affiliation(s)
- Anthony R Mawson
- Behavioral and Environmental Health Unit, School of Health Sciences, College of Public Service, Jackson State University, Jackson, MS, USA
| | - Ike Eriator
- Department of Anesthesiology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Sridhar Karre
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USA
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Agrawal SR, Rajput A, Jain AP. Leukocytoclastic vasculitis and acute allergic interstitial nephritis following ceftriaxone exposure. J Pharmacol Pharmacother 2014; 5:268-70. [PMID: 25422573 PMCID: PMC4231562 DOI: 10.4103/0976-500x.142453] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 03/21/2014] [Accepted: 04/25/2014] [Indexed: 11/28/2022] Open
Abstract
Leukocytoclastic vasculitis (LCV), also known as hypersensitivity vasculitis is a small vessel inflammatory disease which mainly involves the postcapillary venules. A 17-year-old girl developed palpable purpura over lower limbs and acute allergic interstitial nephritis 5 days after exposure to ceftriaxone. Skin biopsy from the lesion over lower limbs confirmed the diagnosis of LCV. Discontinuation of drug and treatment with steroid resulted in resolution of skin lesions and normalization of kidney functions. Beta-lactams are commonly used antibiotics in various types of infection in day-to-day practice. LCV, a rare complication of ceftriaxone should be kept in mind while using this drug.
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Affiliation(s)
- Sachin R Agrawal
- Department of Internal Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra India
| | - Atul Rajput
- Department of Internal Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra India
| | - A P Jain
- Department of Internal Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra India
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Bataille S, Daumas A, Tasei AM, Jourde-Chiche N, Dussol B, Burtey S, Taugourdeau S, Berland Y, Chiche L. Vancomycin-induced Henoch-Schönlein purpura: a case report. J Med Case Rep 2012; 6:106. [PMID: 22490390 PMCID: PMC3348025 DOI: 10.1186/1752-1947-6-106] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 04/10/2012] [Indexed: 11/10/2022] Open
Abstract
Introduction Henoch-Schönlein purpura is a small-vessel systemic vasculitis. Although its exact pathophysiology remains unknown, Henoch-Schönlein purpura has been reported in association with various medical conditions including hypersensitivity. We report the case of a patient with vancomycin-induced Henoch-Schönlein purpura. Case presentation A 42-year-old Caucasian man who had previously undergone a heart transplant was diagnosed as having an intra-abdominal abscess after he underwent a Hartmann procedure. At 15 days after initiation of antibiotic therapy including vancomycin, he developed a purpuric rash of the lower limbs, arthralgia, and macroscopic hematuria. At that time, our patient was already on hemodialysis for end-stage renal disease. Henoch-Schönlein purpura was diagnosed. After a second 15-day course of vancomycin, a second flare of Henoch-Schönlein purpura occurred. Skin biopsies showed leucocytoclastic vasculitis with IgA deposits and eosinophils in the peri-capillary inflammatory infiltrate, suggesting an allergic mechanism. After vancomycin was stopped, we did not observe any further flares. Only five cases of isolated cutaneous vasculitis, one case of lupus-like syndrome and one case of Henoch-Schönlein purpura after vancomycin treatment have been described to date in the literature. Conclusions Clinicians should be aware that systemic vasculitis can be induced by some treatments. Vancomycin is a widely prescribed antibiotic. Occurrence of rare but serious Henoch-Schönlein purpura associated with vancomycin requires its prompt discontinuation.
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Affiliation(s)
- Stanislas Bataille
- Centre de Néphrologie et Transplantation rénale, Hôpital de la Conception, Assistance Publique des Hôpitaux de Marseille, 147 Boulevard Baille, 13005 Marseille, Université Aix-Marseille II, France.
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Affiliation(s)
- B H Millette
- Department of Cardiology, John Radcliffe Hospital, Oxford OX3 9DU.
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Vancomycin hypersensitivity diagnosed by lymphocyte blast transformation. Case Rep Pediatr 2011; 2011:562620. [PMID: 22606516 PMCID: PMC3350173 DOI: 10.1155/2011/562620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Accepted: 09/21/2011] [Indexed: 01/30/2023] Open
Abstract
A 15-year-old male admitted for Pott's puffy tumor developed recurrent episodes of fever, diffuse morbilliform rash, eosinophilia, and tubulointerstitial nephritis while on multiple antibiotics. Lymphocyte blast transformation (LBT), a method of detecting cellular immune response by measuring levels of interferon-γ (IFN-γ), was used to diagnose vancomycin hypersensitivity and guide antibiotic selection.
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12
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Vancomycin-associated leukocytoclastic vasculitis. Case Rep Infect Dis 2011; 2011:356370. [PMID: 22567469 PMCID: PMC3336219 DOI: 10.1155/2011/356370] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 05/21/2011] [Indexed: 11/29/2022] Open
Abstract
Vancomycin is U.S. Food and Drug Administration (FDA) approved for treatment of serious infections caused by methicillin-resistant Staphylococcus aureus (MRSA) or in individuals who have failed, cannot tolerate, or are allergic to other antibiotics. Very few cases of vancomycin-associated leukocytoclastic vasculitis have been published. We report on a patient who developed pruritus and palpable purpura in both lower extremities after receiving six days of intravenous vancomycin. Skin biopsy revealed leukocytoclastic vasculitis.
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Heijnen EBJ, Bentala M, van der Meer NJM. Purpura in a patient receiving vancomycin: a leukoclastic vasculitis? J Cardiothorac Vasc Anesth 2010; 25:390-1. [PMID: 20427206 DOI: 10.1053/j.jvca.2010.02.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Indexed: 11/11/2022]
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2009. [DOI: 10.1002/pds.1846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Sterling JA. Recent Publications on Medications and Pharmacy. Hosp Pharm 2009. [DOI: 10.1310/hpj4409-822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest regarding a broad scope of topics are abstracted monthly.
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