NEURALGIC
AMYOTROPHY ASSOCIATED WITH ANTIBIOTIC THERAPY
Finstad K, Guajardo JR, Scoville C
The Annals of Pharmacotherapy 2008; 42:1344-1347
RIASSUNTO
Viene riportato il caso di una donna di 22 anni, con fibrosi cistica,
trattata con vancomicina, tobramicina e piperacillina/tazobactam per un'esacerbazione
polmonare della sua malattia, in cui si è sviluppata amiotrofia
neuralgica. Si tratta di una condizione rara di eziologia sconosciuta
che fino ad ora non era mai stata associata all'uso di antibiotici. E'
probabile che il responsabile di questa reazione avversa sia vancomicina,
ma non è possibile affermarlo definitivamente con le evidenze disponibili.
I clinici dovrebbero sospettare questa reazione avversa in presenza di
sintomatologia neurologica complessa in pazienti in terapia con antibiotici,
in particolare vancomicina.
CASE
REPORT
OBJECTIVE: To report a case of neuralgic amyotrophy associated with antibiotic
therapy.
CASE SUMMARY: A 22-year-old male with cystic fibrosis had been nonadherent
to treatment for 4 years; when he returned to the clinic with symptoms,
his forced expiratory volume in 1 second dropped from 84% predicted to
43% predicted. He was admitted to the hospital for treatment after failing
to improve on oral ciprofloxacin and inhaled tobramycin. Treatment was
initiated with intravenous tobramycin 560 mg daily and piperacillin/tazobactam
4.5 g infused every 6 hours. He continued inhaled tobramycin 300 mg twice
daily, his home doses of pancreatic replacement enzymes and vitamins,
albuterol 2.5 mg by high flow nebulizer (HFN) 4 times daily, and dornase
alpha 2.5 by HFN daily. Sputum cultures were positive for methicillin-resistant
Staphylococcus aureus, and intravenous vancomycin 1 g every 8 hours was
added to the treatment regimen on hospital day 7. The patient developed
bilateral shoulder pain followed by decreased function of his upper extremities
2 days later. He was treated with oral ibuprofen 600 mg every 6 h and
oral cyclobenzaprine 5 mg daily, which improved his pain, but the shoulder
stiffness remained throughout his hospital stay and persisted for 2 months
following discharge. These symptoms resolved but recurred rapidly (within
24 h) and were more debilitating following a second exposure to the same
antibiotics at the same doses 8 months later when the patient was readmitted
for treatment of another cystic fibrosis-related pulmonary exacerbation.
DISCUSSION: To our knowledge, this is the first case report illustrating
neuralgic amyotrophy triggered by exposure to the antibiotics vancomycin,
tobramycin, and piperacillin/tazobactam. After analysis of the case, ruling
out other possibilities and using the Naranjo probability scale, we found
that there is a highly probable likelihood that the symptoms presented
by our patient were secondary to his drug therapy. Neuralgic amyotrophy
is a rare condition of unknown etiology that has never before been associated
with administration of these antibiotics, individually or in combination.
Because of the specifics of the clinical history, we were unable to ascertain
whether this complication was due to a single antibiotic or to the combination.
It is quite possible that vancomycin was the only culprit, but impossible
to ensure with the available evidence.
CONCLUSIONS: Clinicians should be aware of this adverse reaction when
facing similar complex neurologic symptoms in patients who are receiving
the antibiotic treatment described here, especially vancomycin.
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