teicoplanin-induced vasculitis with cutaneous and renal involvement

CASE REPORT

Teicoplanin-induced vasculitis with cutaneous andrenal 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

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KEYWORDSTeicoplanin;Glycopeptide;Renal failure;Rash;Vasculitis

63-4453/$30.00 Q 2005 The Britishi:10.1016/j.jinf.2005.01.004

* Corresponding author. Address: Depopical Diseases, London School odicine, Keppel St, London WC1E 7H16; fax: C44 20 7612 7860.E-mail address: michael.brown@lsh

Abstract We present a case of cutaneous vasculitis with renal impairment. Thisdeveloped whilst receiving teicoplanin for Staphylococcus aureus osteomyelitis ofthe hip.Q 2005 The British Infection Society. Published by Elsevier Ltd. All rights reserved.

Case report

A 67-year-old man with transfusion-dependentmyelodysplastic syndrome presented with a 3 dayhistory of fever, and of pain in his right hip. Onexamination he was tender over the greatertrochanter with a decreased range of movement.

Investigations revealed an elevated C-reactiveprotein (CRP) concentration of 251 mg/l (normalrange (NR) !10 mg/l), and an elevated white cellcount 14.4!109/l (NR 4–11!109/l); urea was raisedat 14.3 mmol/l (NR 2.5–6.7 mmol/l) with serumcreatinine 110 mmol/l (NR 70–150 mmol/l). An MRIscan of his hip showed synovitis of the right hip jointwith inflammation in the adjacent gluteal muscle.Penicillin-sensitive Staphylococcus aureus wasisolated from blood cultures taken at admission.

Infection Society. Published by

artment of Infectious andf Hygiene and TropicalT, UK. Tel.: C44 20 7927

tm.ac.uk (M. Brown).

Septic arthritis with infection extending into themuscle was diagnosed.

Whilst awaiting identification and antibioticsensitivities of the organism he received intrave-nous flucloxacillin 1 g 6-hourly for 2 days, and oncesensitivities were available ceftriaxone 2 g 12-hourly for 11 days. When he improved, treatmentwas changed to oral amoxicillin 1 g 8-hourly. Hispyrexia resolved, inflammatory markers declined(CRP fell to 35 mg/l) and his renal function normal-ised (urea 6.1 mmol/l and creatinine 76 mmol/l).However, after 12 days of oral amoxicillin his feverreturned, the hip pain increased, and the CRP roseto 69 mg/l. A second MRI scan indicated inflamma-tory changes of the right acetabulum with alteredsignal throughout the bones of the pelvis. Due tothe failure of oral therapy, and problems withperipheral venous access, he was changed tointramuscular teicoplanin 400 mg daily. On teico-planin his fever, hip pain and inflammatory markerspromptly subsided; his renal function remainednormal.

After 17 days of teicoplanin he reported a painfulrash on his legs. Examination revealed tender

Journal of Infection (2005) 51, e185–e186

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Elsevier Ltd. All rights reserved.

S.A.E. Logan et al.e186

purpura and pitting oedema over his lower legs.Serum creatinine had risen to 165 mmol/l and urea20 mmol/l. The unspun midstream urine specimencontained O100!106/l erythrocytes and hyalinecasts. Biopsy of the rash showed features typical ofa leucocytoclastic vasculitis. Other causes of avasculitic rash were explored: immunoglobulin andcomplement levels were normal; anti-nuclear anti-bodies, extractable nuclear antibodies, perinuclearand cytoplasmic anti-neutrophil cytoplasmic anti-bodies, and cryoglobulins were not detected. Theeosinophil count was not elevated. His most recentblood transfusion for myelodysplasia was O7 daysprior to onset of the rash. The CRP concentrationwas 40 mg/l with an erythrocyte sedimentation rateof 73 mm/1st hour.

He was treated with prednisolone 40 mg/day andreducing over 2 weeks, with immediate improve-ment. Teicoplanin was replaced with oral fluclox-acillin 500 mg 6-hourly for a further 8 days. At 2months’ follow-up, the rash had completelyresolved, his CRP was 6 mg/l, his renal functionhad improved though his serum creatinine remainedhigher than his baseline level, at 147 mmol/l.

Discussion

Leucocytoclastic vasculitis following antibioticadministration is well documented, in particularwith b-lactams.1,2 In this instance the rash was notlikely to be due to b-lactam therapy, which hadstarted 45 days, and stopped 17 days, prior to theonset of the rash. Furthermore, a b-lactam (flu-cloxacillin) was re-instituted after the onset of therash without inducing relapse.

The glycopeptide antibiotic vancomycin hasbeen associated with several adverse drug reactionsincluding ‘red-man syndrome’ and less frequentlyvasculitis.3–5 Teicoplanin has a better safety profilethan vancomycin6 though allergic reactions such as

fever, maculopapular rash and bronchospasm arefairly common (Dr J.M. Raine, MHRA, personalcommunication). To our knowledge, this is thefirst reported case of vasculitis associated withteicoplanin monotherapy. A vasculitic rash has beendescribed during treatment with vancomycin andsubsequent teicoplanin therapy, but it is not clearwhich agent was responsible.7

The U.K. Medicine and Healthcare productsRegulatory Agency (MHRA) is aware of eightreported cases of teicoplanin-associated renalimpairment and two other cases of cutaneousvasculitis (Dr J.M. Raine, MHRA, personal communi-cation). It has been documented rarely by themanufacturers and is not listed as a side effect ofthe drug (personal communication, N. Roebuck,Aventis Pharma Ltd, U.K.).

Teicoplanin is often chosen over alternativessuch as vancomycin due to its safety profile.Clinicians should be aware of this rare potentiallyserious adverse reaction.

References

1. Hannedouche T, Fillastre J. Penicillin-induced hypersensitiv-ity vasculitides. J Antimicrob Chemother 1987;20(1):3–5.

2. Garcıa-Porrua C, Gonzalez-Gay M, Lopez-Lazaro L. Drugassociated cutaneous vaculitis in adults in NorthwesternSpain. J Rheumatol 1999;26(9):1942–4.

3. Khurana C, de Belder M. Red-man syndrome after vancomy-cin: potential cross-reactivity with teicoplanin. Postgrad MedJ 1999;75:41–3.

4. McElrath M, Goldberg D, Neu H. Allergic cross-reactivity ofteicoplanin 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 ofteicoplanin. J Antimicrob Chemother 1991;27(Suppl B):69–73.

7. Marshall C, Street A, Galbraith K. Glycopeptide-inducedvasculitis—cross-reactivity between vancomycin and teico-planin. J Infect 1998;37:82–3.