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Associate Professor Department of Pharmacology and Therapeutics Khulna Medical College Khulna, Bangladesh
Assistant Professor Department of Pharmacology Bangabandhu Sheikh Mujib Medical University Shabagh Dhaka 1000, Bangladesh fax 88 02 912 2176 srkhasru{at}bdcom.com
Published Online, May 10, 2005. www.theannals.com, DOI 10.1345/aph.1E613
Case Report. A healthy 15-year-old male, weighing 58 kg, was admitted into a private-sector healthcare facility, where he underwent nasal polypectomy. He was subsequently treated with oral levofloxacin 500 mg once daily. The boy was discharged from the clinic the next day and was instructed to continue the drug as an outpatient for an additional 9 days. He denied the use of any other medications. On the ninth day of taking levofloxacin, the patient returned to the clinic with fever, joint pain, severe general prostration, and a pruritic rash involving all extremities, abdomen, and back. He was referred to the local medical college hospital.
On admission, the patient was in distress. His vital signs included BP 125/85 mm Hg, HR 130 beats/min, RR 32 breaths/min and regular, and oral T 39.2 °C. Physical examination revealed large blistering lesions, erythematous rash, early mucosal sloughing, and swollen edematous extremities. The exfoliative rash progressed within the next 40 hours to involve 80% of the patient's total body surface area, with positive Nikolsky's sign, including the face and forehead, complete anterior and posterior torso, upper extremities, lower extremities, thighs, gluteal regions, and eyes. Oral, nasal, and perianal mucosa were markedly affected. These findings were consistent with a diagnosis of TEN. Levofloxacin was implicated as the causative agent. The patient's total white blood cell count was 12.7 x 103/mm3, with neutrophils 50%, lymphocytes 35%, eosinophils 13%, and monocytes 2%; erythrocyte sedimentation rate was 37 mm/h in the first hour.
The patient was kept under a clean mosquito net. He was then managed with fluid resuscitation, povidone iodine 1% weight per volume (w/v) was applied as mouthwash, and povidone iodine 10% w/v and neomycin/bacitracin (0.25%/0.5%) powder was applied to the affected skin surface. He was given intravenous ceftriaxone 2 g once daily and dexamethasone 5 mg intravenously every 6 hours. The patient's eye condition was treated with one drop of dexamethasone 0.1% w/v 6 times every hour, one drop of hypromellose 0.3% every hour, and one drop of homatropine 2% w/v once daily. Despite all of these efforts, the patient died 57 hours after admission to the hospital.
Discussion. The Naranjo probability scale indicated a probable relationship between TEN and levofloxacin therapy in this patient.2 As of April 28, 2005, many cases of life-threatening TEN have been reported with different fluoroquinolones, of which few were fatal.3-5 Healthcare professionals should be familiar with the early signs and symptoms of exfoliative dermatitis with fluoroquinolones, as well as other agents, and should also realize that early withdrawal of the offending agent is the crucial step in successful management of these adverse reactions.
References
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