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Levofloxacin-Induced Autoimmune Hemolytic Anemia

Major, USAF, BSC, Pharmacy Practice Resident, Department of Clinical Pharmacy Services, David Grant USAF Medical Center, Travis Air Force Base, CA

Sian M Carr-Lopez, PharmD

Professor and Vice-Chair, Thomas J Long School of Pharmacy and Health Sciences, University of the Pacific at Stockton; Regional Coordinator and Pharmacy Residency Program Director, David Grant USAF Medical Center

James M Probasco, MD

Captain, USAF, MC, Family Practice Resident, Department of Family Practice, David Grant USAF Medical Center

Peter G Crawley, MD PhD

Captain, USAF, MC, Internal Medicine Resident, Department of Internal Medicine, David Grant USAF Medical Center

Reprints: Young R Oh PharmD, Major, USAF, BSC, David Grant USAF Medical Center, 101 Bodin Circle, Travis Air Force Base, CA 94535-1800, FAX 707/423-7994, E-mail young.oh{at}60mdg.travis.af.mil

OBJECTIVE: To report a case of autoimmune hemolytic anemia (AIHA) secondary to levofloxacin.

CASE SUMMARY: An 82-year-old white man was treated with levofloxacin 500 mg/d for cellulitis. Three days following completion of levofloxacin therapy, the patient presented to the emergency department with severe jaundice, dizziness, and loss of vision. He received packed red blood cells (PRBCs) and was discharged home. Two days later at the follow-up visit, he was diagnosed with AIHA secondary to levofloxacin. The patient was hospitalized and treated with a tapering dose of prednisone and additional PRBC infusion. He was discharged from the hospital in stable condition after 3 days. Repeated hematologic laboratory studies following discharge demonstrated that the hemolytic anemia had resolved.

DISCUSSION: Hemolytic anemia due to levofloxacin is an extremely rare, but potentially fatal, adverse drug event. An objective causality assessment revealed that the adverse reaction was probable. To our knowledge, this is the first published case of levofloxacin-induced AIHA. However, there are published case reports of hemolytic anemia with other fluoroquinolones including ciprofloxacin (n = 12) and temafloxacin (n = 95). Temafloxacin was withdrawn from the market in 1992 due to this adverse effect. The mechanism by which levofloxacin triggers hemolytic anemia is unknown. We believe that an immune-mediated reaction is most likely.

CONCLUSIONS: Levofloxacin-induced AIHA is a rare but serious complication of therapy. Immediate discontinuation of the offending medication and treatment of the hemolytic anemia are essential. Until more information is available, levofloxacin should not be prescribed for patients with previous reactions to any fluoroquinolone.

Key Words: hemolytic anemia, autoimmune, levofloxacin

Published Online, June 10, 2003. www.theannals.com, DOI 10.1345/aph.1C525

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