Levofloxacin induced Stevens-Johnson syndrome/ toxic epidermal necrolysis overlap syndrome: case reports

摘要

Fluoroquinolones are widely used because of their broadspectrum of activity. Their benefit-risk profile needscareful evaluation as they can induce T cell-dependentreactions including Stevens-Johnson syndrome (SJS) andtoxic epidermal necrolysis (TEN). Here we present tworare cases of SJS/TEN overlap syndrome and SJS causedby levofloxacin. Case 1. A 70-year-old woman with ahistory of chronic obstructive pulmonary disease wastreated with levofloxacin for acute bronchitis. After takingmedications for 10 days she complained of generalizedskin eruptions and mucosal erosions. On the day ofadmission in the burn intensive care department 28% ofher body surface was covered by rash, blistering and epidermalpeeling; 65% of body surface presented dusky redskin. Levofloxacin was stopped and our patient was treatedwith topical solution to keep the wounds moist, fluidreplacement, well balanced nutrition, systemic corticosteroidsand intravenous immune globulin (IVIG). Wealso administrated teicoplanin because of S. aureusinfection of central i.v. catheter confirmed by a positiveculture. She was subsequently treated with meropenembecause of a Klebsiella pneumoniae urinary tract infection.The main laboratory findings were: anemia, leukocytosisand increased CRP levels. The diagnosis wasperformed on the basis of clinical and histological features.Gradually her symptoms improved and the epidermalpeeling also subsided. Case 2. A 72-year-oldwoman was referred to our department with multipleskin lesions involving more than 50 % of the total bodysurface area occurred after 2 weeks of starting levofloxacintreatment for pneumonia. She developed high feverand had the appearance of a severe burn patient.Laboratory analysis showed anaemia, leukocytosis,hypoalbuminaemia and elevated procalcitonin and CRP.The levofloxacin treatment was stopped immediately andreplaced with teicoplanin and meropenem. Subsequentlybecause of A. baumanii complex infection of the centrali.v. catheter she was treated also with colistin. Our managementincluded IVIG treatment, intravenous glucocorticoids,proper fluid balance, attention to nutritionalstatus and pain relief. The skin lesions healed within3 weeks and the patient left our department in good generalcondition.ConclusionsEven if there are little published data on levofloxacinTEN/SJS, this fluoroquinolone can be implicated inthese delayed ADR requiring early diagnosis and carefulmonitoring.