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Clinical Assistant Professor of Pharmacy Practice Harrison School of Pharmacy Auburn University Auburn, Alabama 301 Governors Drive Huntsville, Alabama 35801 fax 256/551-4542 wargoka{at}auburn.edu
Assistant Professor of Internal Medicine Department of Internal Medicine School of Medicine University of Alabama—Birmingham Huntsville Regional Medical Campus Huntsville, Alabama
Assistant Professor of Internal Medicine Department of Internal Medicine School of Medicine University of Alabama—Birmingham Huntsville Regional Medical Campus
Published Online, July 26, 2005. www.theannals.com, DOI 10.1345/aph.1G140
Case Report. An 18-year-old white woman presented to her primary care physician with generalized malaise and sore throat. She had no previous medical history, no known drug allergies, and was taking no medications. Cervical lymphadenopathy was detected; however, subsequent Streptococcus and Monospot tests were negative.2 Bacterial tonsillitis was suspected, and therapy with amoxicillin/clavulanate was initiated (Figure 1). Two days later, after the patient developed difficulty swallowing and increased swelling of the neck, an ear, nose, and throat specialist diagnosed infectious mononucleosis following a positive Monospot test. Amoxicillin/clavulanate was discontinued, and intravenous ampicillin/sulbactam was begun at home.
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The following day, the patient was admitted to our facility. At that time, she had a diffuse erythematous, nonblanching, pruritic, maculopapular rash on her face and bilaterally on her upper and lower extremities, as well as significant swelling of the joints of the hands. Laboratory values were significant only for sodium 131 mEq/L, white blood cell count 17.64 x 103 (83% neutrophils, 11% bands, 1% lymphocytes, 4% monocytes), absolute CD4+ count 65 cells/mm3, and absolute lymphocyte count of 176 cells/mm3, most likely due to the recent viral illness. HIV, antinuclear antibody, and rheumatoid factor tests were negative, ruling out other potential causes of the rash. Antibiotic therapy was discontinued, and supportive therapy with intravenous fluids, oral and intravenous antihistamines, and intravenous methylprednisolone was introduced. The patient was discharged 6 days after admission, with nearly complete resolution of the rash.
Discussion. Based on the Naranjo probability scale and the time course of events, telithromycin was determined to be the probable cause of the diffuse rash observed in this patient.3 While other causes for the rash, such as serum sickness and angioedema, could not be completely ruled out, they were less likely to have caused this exanthematous and maculopapular, as opposed to urticarial, rash.4 Neither amoxicillin nor ampicillin therapy were likely the cause of the adverse reaction as the rash began to improve upon discontinuation of amoxicillin/ampicillin prior to worsening with telithromycin.
References
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