Unusual Cutaneous Manifestations of Quinolone Therapy

摘要

Fluoroquinolones are generally well-tolerated antibiotics and are commonly associated with central nervous system and gastrointestinal disturbances [1]. The overall frequency of adverse events among fluoroquinolones ranges from 3-40%. Fluoroquinolones are rarely associated with dermatologic adverse events, which occur at an overall rate of 0.5-3% [2]. Photosensitivity is typically the most common dermatological effect; however there are other rare occurring dermatologic effects such as vasculitis, erythema multiforme, eruptions with hemorrhagic bullae, and Henoch-Sch?nlein purpura [2]. Few case reports have been published on fluoroquinolone induced Henoch-Sch?nlein purpura and vasculitis [3-9]. We now report a case of purpura associated with levofloxacin. Case Report A 50 year old white female, with no history of drug allergies, was seen because of purpuric lesions under her fingernails appearing as splinter hemorrhages. The lesions were present in the third, fourth, and fifth fingernails of the left hand as well as in the fourth and fifth fingernails of the right hand. She was initially treated for a urinary tract infection with levofloxacin for five days with good clinical response. Seven days later she developed a bruised quality under the fingernails, which led her to seek further medical care (Figure 1). The patient did not recall any recent trauma to the fingernails and also denied any recent gardening or animal exposure. Her nails were negative for any transverse grooves on the fingernails (Beau’s lines). The nails were also negative for leukonychias, which usually present as white spots or streaks on the nail due to separation of the nail and bed. Medications at the time included norethindrone/mestranol (Ortho-Novum?) 1/50 and black cohosh for perimenopausal symptoms. She also used clobetasol topical cream as needed for eczema. Her medical history was negative for hypertension, diabetes, or any hematologic disorder. Laboratory results revealed normal electrolytes, hemoglobin, platelets, and white blood cells. Additional results included negative anti-nuclear antibody and normal C - reactive protein. Based on her recent history and clinical presentation the patient was worked up for possible endocarditis. The levafloxacin had been stopped but was then restarted by her primary care physician with a presumptive diagnosis of sepsis from an unclear source. In addition , linezolid 600 mg by mouth twice daily was also started .She received 4 weeks of these antibiotics. Echocardiogram was negative and blood cultures revealed no growth after 5 days. During the course of antimicrobial therapy she was sent to the Mayo clinic for further evaluation of the purpura under her fingernails. The mayo clinic was unable to add any further data/diagnostic criteria to her current problem. They did however, stop all her antibiotics. The purpura under the patient’s fingernails resolved spontaneously three weeks after initial presentation.