Ofloxacin-induced vasculitis

Ceftriaxone-induced leukocytoclastic vasculitis: a case report and literature review of antibiotic-induced leukocytoclastic vasculitis

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.

Leukocytoclastic Vasculitis with Systemic Involvement Associated with Ciprofloxacin Therapy: Case Report and Review of the Literature

A 71-year-old woman presented with constitutional signs and lower extremity palpable purpura after being prescribed a four-day course of 500 mg of ciprofloxacin two times daily for a gastrointestinal infection. She was admitted for inpatient treatment. During the third hospital day, she presented with an episode of abundant hematemesis while her skin lesions remained unchanged. Upper endoscopy revealed multiple lesions consistent with vasculitis and histological examination of the skin biopsy disclosed a leukocytoclastic vasculitis. The patient was successfully treated with prednisone following ciprofloxacin discontinuation. Complete resolution of the lesions on drug withdrawal strongly suggested drug toxicity, which was further supported by a score of 8 in the Naranjo Adverse Drug Reaction Probability Scale. Awareness that the development of skin and gastrointestinal lesions following administration of ciprofloxacin may be a manifestation of ciprofloxacin-induced vasculitis can help early detection, treatment, and lead to an overall good prognosis.

Cutaneous leukocytoclastic vasculitis associated with levofloxacin therapy

Many cases of cutaneous vasculitis are drug-induced with histology revealing leukocytoclastic vasculitis (LCV). We present a case of levofloxacin-associated LCV successfully treated with prednisone and cessation of the offending drug. Although case reports describe a link between LCV and older fluoroquinolones, such as ciprofloxacin and ofloxacin, recent reports have implicated the newer fluoroquinolone levofloxacin. Recognition of fluoroquinolone-induced cutaneous vasculitis is important as continuation or re-exposure of the offending agent may have life-threatening consequences.

Ocular toxicity of fluoroquinolones

The ocular toxicity of fluoroquinolones and the risks of their use in the treatment of ocular infection were reviewed. Systematic identification, selection, review and synthesis of published English-language studies relating to fluoroquinolone use and safety in animals and humans was conducted. Although not free of complications, fluoroquinolones are generally safe when used to treat ocular infection. Ocular toxicity appears to be dose-dependent and results from class-effects and specific fluoroquinolone structures. Phototoxicity and neurotoxicity have been reported, and toxic effects on ocular collagen may be associated with Achilles tendinopathy. Corneal precipitation may provide an advantageous drug depot but delay healing and result in corneal perforation in approximately 10% of cases. Although human toxicity studies are limited, the current recommended dose for intracameral injection of ciprofloxacin is less than 25 microg. Intravitreal injections of ciprofloxacin 100 microg, ofloxacin 50 microg/mL, trovafloxacin 25 microg or less, moxifloxacin 160 microg/0.1 mL or less and pefloxacin 200 microg/0.1 mL are considered safe.

Cutaneous and systemic manifestations of drug-induced vasculitis

OBJECTIVE

To evaluate the literature for published cases of drug-induced vasculitis with cutaneous and/or systemic manifestations.

DATA SOURCES

The MEDLINE database was searched from 1965 to December 1999 for articles focusing on drugs and vasculitis, using various search terminologies (e.g., Churg-Strauss syndrome, Goodpasture's syndrome, Henoch-Schönlein purpura, various drugs suspected to induce vasculitis). Cases were included when they met the established criteria as described in the methodology.

DATA SYNTHESIS

Drugs found to be most frequently associated with vasculitis were propylthiouracil, hydralazine, colony-stimulating factors, allopurinol, cefaclor, minocycline, D-penicillamine, phenytoin, isotretinoin, and methotrexate. The interval between the first exposure and appearance of symptoms was reported to be extremely variable (hours to years). Vasculitis has occurred after drug dosage increases and after rechallenge with the suspected drug. In the majority of cases, vasculitis has resolved after discontinuing the drug. Patients with more severe, often life-threatening, manifestations have required treatment with corticosteroids, plasmapheresis, hemodialysis, or cyclophosphamide. Death was the result in 10% of all published cases, with a predominance in patients in whom multiple organ systems were involved.

CONCLUSIONS

Clinicians need to be suspect of drug-induced vasculitis to enable prompt diagnosis and treatment. This should improve patient outcomes based on the data referenced for this article.