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Teicoplanin-induced vasculitis with cutaneous and renal involvement
Journal of Infection (2005) 51, e185–e186
www.elsevierhealth.com/journals/jinf
CASE REPORT
Teicoplanin-induced vasculitis with cutaneous and renal involvement S.A.E. Logan, M. Brown*, R.N. Davidson Department of Infection and Tropical Medicine, Northwick Park Hospital, Harrow, Middlesex HA5 3UJ, UK Accepted 10 January 2005
KEYWORDS Teicoplanin; Glycopeptide; Renal failure; Rash; Vasculitis
Abstract We present a case of cutaneous vasculitis with renal impairment. This developed whilst receiving teicoplanin for Staphylococcus aureus osteomyelitis of the hip. Q 2005 The British Infection Society. Published by Elsevier Ltd. All rights reserved.
Case report A 67-year-old man with transfusion-dependent myelodysplastic syndrome presented with a 3 day history of fever, and of pain in his right hip. On examination he was tender over the greater trochanter with a decreased range of movement. Investigations revealed an elevated C-reactive protein (CRP) concentration of 251 mg/l (normal range (NR) !10 mg/l), and an elevated white cell count 14.4!109/l (NR 4–11!109/l); urea was raised at 14.3 mmol/l (NR 2.5–6.7 mmol/l) with serum creatinine 110 mmol/l (NR 70–150 mmol/l). An MRI scan of his hip showed synovitis of the right hip joint with inflammation in the adjacent gluteal muscle. Penicillin-sensitive Staphylococcus aureus was isolated from blood cultures taken at admission.
* Corresponding author. Address: Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK. Tel.: C44 20 7927 2116; fax: C44 20 7612 7860. E-mail address: [email protected] (M. Brown).
Septic arthritis with infection extending into the muscle was diagnosed. Whilst awaiting identification and antibiotic sensitivities of the organism he received intravenous flucloxacillin 1 g 6-hourly for 2 days, and once sensitivities were available ceftriaxone 2 g 12hourly for 11 days. When he improved, treatment was changed to oral amoxicillin 1 g 8-hourly. His pyrexia resolved, inflammatory markers declined (CRP fell to 35 mg/l) and his renal function normalised (urea 6.1 mmol/l and creatinine 76 mmol/l). However, after 12 days of oral amoxicillin his fever returned, the hip pain increased, and the CRP rose to 69 mg/l. A second MRI scan indicated inflammatory changes of the right acetabulum with altered signal throughout the bones of the pelvis. Due to the failure of oral therapy, and problems with peripheral venous access, he was changed to intramuscular teicoplanin 400 mg daily. On teicoplanin his fever, hip pain and inflammatory markers promptly subsided; his renal function remained normal. After 17 days of teicoplanin he reported a painful rash on his legs. Examination revealed tender
0163-4453/$30.00 Q 2005 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2005.01.004
e186 purpura and pitting oedema over his lower legs. Serum creatinine had risen to 165 mmol/l and urea 20 mmol/l. The unspun midstream urine specimen contained O100!106/l erythrocytes and hyaline casts. Biopsy of the rash showed features typical of a leucocytoclastic vasculitis. Other causes of a vasculitic rash were explored: immunoglobulin and complement levels were normal; anti-nuclear antibodies, extractable nuclear antibodies, perinuclear and cytoplasmic anti-neutrophil cytoplasmic antibodies, and cryoglobulins were not detected. The eosinophil count was not elevated. His most recent blood transfusion for myelodysplasia was O7 days prior to onset of the rash. The CRP concentration was 40 mg/l with an erythrocyte sedimentation rate of 73 mm/1st hour. He was treated with prednisolone 40 mg/day and reducing over 2 weeks, with immediate improvement. Teicoplanin was replaced with oral flucloxacillin 500 mg 6-hourly for a further 8 days. At 2 months’ follow-up, the rash had completely resolved, his CRP was 6 mg/l, his renal function had improved though his serum creatinine remained higher than his baseline level, at 147 mmol/l.
S.A.E. Logan et al. fever, maculopapular rash and bronchospasm are fairly common (Dr J.M. Raine, MHRA, personal communication). To our knowledge, this is the first reported case of vasculitis associated with teicoplanin monotherapy. A vasculitic rash has been described during treatment with vancomycin and subsequent teicoplanin therapy, but it is not clear which agent was responsible.7 The U.K. Medicine and Healthcare products Regulatory Agency (MHRA) is aware of eight reported cases of teicoplanin-associated renal impairment and two other cases of cutaneous vasculitis (Dr J.M. Raine, MHRA, personal communication). It has been documented rarely by the manufacturers and is not listed as a side effect of the drug (personal communication, N. Roebuck, Aventis Pharma Ltd, U.K.). Teicoplanin is often chosen over alternatives such as vancomycin due to its safety profile. Clinicians should be aware of this rare potentially serious adverse reaction.
References Discussion Leucocytoclastic vasculitis following antibiotic administration is well documented, in particular with b-lactams.1,2 In this instance the rash was not likely to be due to b-lactam therapy, which had started 45 days, and stopped 17 days, prior to the onset of the rash. Furthermore, a b-lactam (flucloxacillin) was re-instituted after the onset of the rash without inducing relapse. The glycopeptide antibiotic vancomycin has been associated with several adverse drug reactions including ‘red-man syndrome’ and less frequently vasculitis.3–5 Teicoplanin has a better safety profile than vancomycin6 though allergic reactions such as
1. Hannedouche T, Fillastre J. Penicillin-induced hypersensitivity vasculitides. J Antimicrob Chemother 1987;20(1):3–5. 2. Garcı´a-Porru ´lez-Gay M, Lo ´pez-La ´zaro L. Drug ´a C, Gonza associated cutaneous vaculitis in adults in Northwestern Spain. J Rheumatol 1999;26(9):1942–4. 3. Khurana C, de Belder M. Red-man syndrome after vancomycin: potential cross-reactivity with teicoplanin. Postgrad Med J 1999;75:41–3. 4. McElrath M, Goldberg D, Neu H. Allergic cross-reactivity of teicoplanin and vancomycin. Lancet 1986;i:47. 5. Polk R. Anaphylactoid reactions to glycopeptide antibiotics. J Antimicrob Chemother 1991;27(Suppl B):17–29. 6. Davey P, Williams A. A review of the safety profile of teicoplanin. J Antimicrob Chemother 1991;27(Suppl B): 69–73. 7. Marshall C, Street A, Galbraith K. Glycopeptide-induced vasculitis—cross-reactivity between vancomycin and teicoplanin. J Infect 1998;37:82–3.
www.elsevierhealth.com/journals/jinf
CASE REPORT
Teicoplanin-induced vasculitis with cutaneous and renal involvement S.A.E. Logan, M. Brown*, R.N. Davidson Department of Infection and Tropical Medicine, Northwick Park Hospital, Harrow, Middlesex HA5 3UJ, UK Accepted 10 January 2005
KEYWORDS Teicoplanin; Glycopeptide; Renal failure; Rash; Vasculitis
Abstract We present a case of cutaneous vasculitis with renal impairment. This developed whilst receiving teicoplanin for Staphylococcus aureus osteomyelitis of the hip. Q 2005 The British Infection Society. Published by Elsevier Ltd. All rights reserved.
Case report A 67-year-old man with transfusion-dependent myelodysplastic syndrome presented with a 3 day history of fever, and of pain in his right hip. On examination he was tender over the greater trochanter with a decreased range of movement. Investigations revealed an elevated C-reactive protein (CRP) concentration of 251 mg/l (normal range (NR) !10 mg/l), and an elevated white cell count 14.4!109/l (NR 4–11!109/l); urea was raised at 14.3 mmol/l (NR 2.5–6.7 mmol/l) with serum creatinine 110 mmol/l (NR 70–150 mmol/l). An MRI scan of his hip showed synovitis of the right hip joint with inflammation in the adjacent gluteal muscle. Penicillin-sensitive Staphylococcus aureus was isolated from blood cultures taken at admission.
* Corresponding author. Address: Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT, UK. Tel.: C44 20 7927 2116; fax: C44 20 7612 7860. E-mail address: [email protected] (M. Brown).
Septic arthritis with infection extending into the muscle was diagnosed. Whilst awaiting identification and antibiotic sensitivities of the organism he received intravenous flucloxacillin 1 g 6-hourly for 2 days, and once sensitivities were available ceftriaxone 2 g 12hourly for 11 days. When he improved, treatment was changed to oral amoxicillin 1 g 8-hourly. His pyrexia resolved, inflammatory markers declined (CRP fell to 35 mg/l) and his renal function normalised (urea 6.1 mmol/l and creatinine 76 mmol/l). However, after 12 days of oral amoxicillin his fever returned, the hip pain increased, and the CRP rose to 69 mg/l. A second MRI scan indicated inflammatory changes of the right acetabulum with altered signal throughout the bones of the pelvis. Due to the failure of oral therapy, and problems with peripheral venous access, he was changed to intramuscular teicoplanin 400 mg daily. On teicoplanin his fever, hip pain and inflammatory markers promptly subsided; his renal function remained normal. After 17 days of teicoplanin he reported a painful rash on his legs. Examination revealed tender
0163-4453/$30.00 Q 2005 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2005.01.004
e186 purpura and pitting oedema over his lower legs. Serum creatinine had risen to 165 mmol/l and urea 20 mmol/l. The unspun midstream urine specimen contained O100!106/l erythrocytes and hyaline casts. Biopsy of the rash showed features typical of a leucocytoclastic vasculitis. Other causes of a vasculitic rash were explored: immunoglobulin and complement levels were normal; anti-nuclear antibodies, extractable nuclear antibodies, perinuclear and cytoplasmic anti-neutrophil cytoplasmic antibodies, and cryoglobulins were not detected. The eosinophil count was not elevated. His most recent blood transfusion for myelodysplasia was O7 days prior to onset of the rash. The CRP concentration was 40 mg/l with an erythrocyte sedimentation rate of 73 mm/1st hour. He was treated with prednisolone 40 mg/day and reducing over 2 weeks, with immediate improvement. Teicoplanin was replaced with oral flucloxacillin 500 mg 6-hourly for a further 8 days. At 2 months’ follow-up, the rash had completely resolved, his CRP was 6 mg/l, his renal function had improved though his serum creatinine remained higher than his baseline level, at 147 mmol/l.
S.A.E. Logan et al. fever, maculopapular rash and bronchospasm are fairly common (Dr J.M. Raine, MHRA, personal communication). To our knowledge, this is the first reported case of vasculitis associated with teicoplanin monotherapy. A vasculitic rash has been described during treatment with vancomycin and subsequent teicoplanin therapy, but it is not clear which agent was responsible.7 The U.K. Medicine and Healthcare products Regulatory Agency (MHRA) is aware of eight reported cases of teicoplanin-associated renal impairment and two other cases of cutaneous vasculitis (Dr J.M. Raine, MHRA, personal communication). It has been documented rarely by the manufacturers and is not listed as a side effect of the drug (personal communication, N. Roebuck, Aventis Pharma Ltd, U.K.). Teicoplanin is often chosen over alternatives such as vancomycin due to its safety profile. Clinicians should be aware of this rare potentially serious adverse reaction.
References Discussion Leucocytoclastic vasculitis following antibiotic administration is well documented, in particular with b-lactams.1,2 In this instance the rash was not likely to be due to b-lactam therapy, which had started 45 days, and stopped 17 days, prior to the onset of the rash. Furthermore, a b-lactam (flucloxacillin) was re-instituted after the onset of the rash without inducing relapse. The glycopeptide antibiotic vancomycin has been associated with several adverse drug reactions including ‘red-man syndrome’ and less frequently vasculitis.3–5 Teicoplanin has a better safety profile than vancomycin6 though allergic reactions such as
1. Hannedouche T, Fillastre J. Penicillin-induced hypersensitivity vasculitides. J Antimicrob Chemother 1987;20(1):3–5. 2. Garcı´a-Porru ´lez-Gay M, Lo ´pez-La ´zaro L. Drug ´a C, Gonza associated cutaneous vaculitis in adults in Northwestern Spain. J Rheumatol 1999;26(9):1942–4. 3. Khurana C, de Belder M. Red-man syndrome after vancomycin: potential cross-reactivity with teicoplanin. Postgrad Med J 1999;75:41–3. 4. McElrath M, Goldberg D, Neu H. Allergic cross-reactivity of teicoplanin and vancomycin. Lancet 1986;i:47. 5. Polk R. Anaphylactoid reactions to glycopeptide antibiotics. J Antimicrob Chemother 1991;27(Suppl B):17–29. 6. Davey P, Williams A. A review of the safety profile of teicoplanin. J Antimicrob Chemother 1991;27(Suppl B): 69–73. 7. Marshall C, Street A, Galbraith K. Glycopeptide-induced vasculitis—cross-reactivity between vancomycin and teicoplanin. J Infect 1998;37:82–3.