Stevens Johnson Syndrome Associated with Fluoroquinolones: A Case Series
Stevens Johnson Syndrome is a rare autoimmune disorder which includes skin and mucous membrane. In India, the incidence of Stevens Johnson Syndrome (SJS) is 1.2 to 6 million patients per year. SJS is a very serious and life-threatening hypersensitivity reaction that can occurs due to infections (mycoplasma pneumonia) or as side effects of drugs (Sulfa Drugs, Phenytoin, Carbamazepine, Lamotrigine, Phenobarbital, Allopurinol, Piroxicam, Nevirapine and Diclofenac). Antibiotics can cause SJS and their contribution is around 40%. Fluoroquinolones are prescribed globally (11%) to treat lower respiratory tract infections, gastrointestinal and genitourinary infections. Norfloxacin and Ciprofloxacin are rarely associated with drug induced SJS. Most of the informative data, available on drugs induced SJS are based on case reports or case series. Here, we present three case reports of Fluoroquinolones induced SJS. In the following cases, patients had developed symptoms of SJS within two days. Whereas in Antibiotic induced SJS, it is reported that symptoms of SJS can appear within few days or even after a single dose of taking antibiotics. Therefore, we alleged that Fluoroquinolone could be the possible causative agent in our cases. The causality assessment had done based on the WHO-UMC causality scale and it was probable in all three cases of Fluoroquinolone induced SJS. This assessment generates a strong evidence that Fluoroquinolone induced SJS in all three cases. These patients were treated symptomatically with corticosteroids, parenteral solution and other non-pharmacologic agents and discharged after complete recovery.
2. Garmendia Madariaga A, Santos Palacios S, Guillen-Grima F, Galofre JC.The incidence and prevalence of thyroid dysfunction in Europe: a metaanalysis.J Clin Endocrinol Metab. 2014;99:923–931.
3. Tunbridge WM, Evered DC, Hall R, et al. The spectrum of thyroid disease in a community: the Whickham survey. Clin Endocrinol (Oxf) 1977;7:481–493.
4. Guglielmi R, Grimaldi F, Negro R, et al. Shift from levothyroxine tablets to liquid formulation at breakfast improves quality of life of hypothyroid patients. Endocr Metab Immune Disord Drug Targets. 2018;18:235–240.
5. Elmor R, Sandulli W, Carter CA. The economic impact of changing levothyroxine formulations in difficult-to-treat hypothyroid patients: an evidence-based model. Pharmacoeconomics. 2017;2:1–10.
6. Hennessey JV. The emergence of levothyroxine as a treatment for hypothyroidism. Endocrine. 2017;55:6–18.
7. Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the treatment of hypothyroidism: prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement. Thyroid. 2014;24:1670–1751.
8. Brenta G, Vaisman M, Sgarbi JA, et al. Clinical practice guidelines for the management of hypothyroidism. Arq Bras Endocrinol Metabol.2013;57:265–291.
9. Tamargo J, Le Heuzey JY, Mabo P. Narrow therapeutic index drugs: a clinical pharmacological consideration to flecainide. Eur J Clin Pharmacol.2015;71:549–567.
10. Garber JR, Cobin RH, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012;18:988–1028.
11. Toward Optimized Practice (TOP) Endocrine Working Group. Investigation and management of primary thyroid dysfunction clinical practice guideline. Edmonton, AB: Toward Optimized Practice. 2014. http://www.
topalbertadoctors.org. Accessed 3 Jun 2022.
12. Malaty W. Primary hypothyroidism. 2017. https://bestpractice.bmj.com/topics/en-us/535/pdf/535.pdf. Accessed 4 Jan 2022.
13. Ott J, Promberger R, Kober F, et al. Hashimoto’s thyroiditis affects symptom load and quality of life unrelated to hypothyroidism: a prospective casecontrol study in women undergoing thyroidectomy for benign goiter.
14. Shin YW, Choi YM, Kim HS, et al. Diminished quality of life and increased brain functional connectivity in patients with hypothyroidism after total thyroidectomy. Thyroid. 2016;26:641–649.
15. Vigario Pdos S, Vaisman F, Coeli CM, et al. Inadequate levothyroxine replacement for primary hypothyroidism is associated with poor healthrelated quality of life-a Brazilian multicentre study. Endocrine. 2013;44:434–440.
16. Thvilum M, Brandt F, Almind D, et al. Excess mortality in patients diagnosed with hypothyroidism: a nationwide cohort study of singletons and twins. J Clin Endocrinol Metabol. 2013;98:1069–1075.
17. Kraut E, Farahani P. A systematic review of clinical practice guidelines’recommendations on levothyroxine therapy alone versus combination therapy (LT4 plus LT3) for hypothyroidism. Clin Invest Med. 2015;38:E305–E313.
18. Chaker L, Bianco AC, Jonklaas J, Peeters RP. Hypothyroidism. Lancet.2017;390:1550–1562.
19. Singh N, Singh PN, Hershman JM. Effect of calcium carbonate on the absorption of levothyroxine. JAMA. 2000;283:2822-2825.
20. Zamfirescu I, Carlson HE. Absorption of levothyroxine when coadministered with various calcium formulations. Thyroid. 2011;21(5):483-486.
21. Singh N, Weisler SL, Hershman JM. The acute effect of calcium carbonate on the intestinal absorption of levothyroxine. Thyroid. 2001;11:967-971.
22. Mazokopakis EE, Giannakopoulos TG, Starakis IK. Interaction between levothyroxine and calcium carbonate. Can Fam Physician. 2008;54(1):39.
23. Csako G, McGriff NJ, Rotman-Pikielny P, et al. Exaggerated levothyroxine malabsorption due to calcium carbonate supplementation in gastrointestinal disorders. Ann Pharmacother. 2001;35(12):1578-1583.
24. Butner LE, Fulco PP, Feldman G. Calcium carbonate-induced hypothyroidism. Ann Intern Med. 2000;132(7):595.
25. Schneyer CR. Calcium carbonate and reduction of levothyroxine efficacy.JAMA. 1998;279(10):750.
26. A Irving S, Vadiveloo T, Leese GP. Drugs that interact with levothyroxine:an observational study from the Thyroid Epidemiology, Audit and Research Study (TEARS). Clin Endocrinol (Oxf). 2015;82(1):136-141.
27. Diskin CJ, Stokes TJ, Dansby LM, et al. Effect of phosphate binders upon TSH and L-thyroxine dose in patients on thyroid replacement. Int Urol Nephrol. 2007;39(2):599-602.
28. Centanni M, Gargano L, Canettieri G, et al. Thyroxine in goiter, Helicobacter pylori infection, and chronic gastritis. N Engl J Med. 2006;354(17):1787-1795.
29. Sachmechi I, Reich DM, Aninyei M, Wibowo F, Gupta G, Kim PJ. Effect of proton pump inhibitors on serum thyroid-stimulating hormone level in euthyroid patients treated with levothyroxine for hypothyroidism. Endocr Pract. 2007;13(4):345-349.
30. Irving SA, Vadiveloo T, Leese GP. Drugs that interact with levothyroxine:an observational study from the Thyroid Epidemiology, Audit and Research Study (TEARS). Clin Endocrinol (Oxf). 2015;82(1):136-141.
31. Dietrich JW, Gieselbrecht K, Holl RW, Boehm BO. Absorption kinetics of levothyroxine is not altered by proton-pump inhibitor therapy. Horm Metab Res. 2006;38(1):57-59.
32. Ananthakrishnan S, Braverman LE, Levin RM, Magnani B, Pearce EN.The effect of famotidine, esomeprazole, and ezetimibe on levothyroxine absorption. Thyroid. 2008;18(5):493-498.
33. Abi-Abib Rde C, Vaisman M. Is it necessary to increase the dose of levothyroxine in patients with hypothyroidism who use omeprazole? Arq Bras Endocrinol Metabol. 2014;58(7):731-736.
34. Vita R, Saraceno G, Trimarchi F, Benvenga S. Switching levothyroxine from the tablet to the oral solution formulation corrects the impaired absorption of levothyroxine induced by proton-pump inhibitors. J Clin Endocrinol Metab.
|Issue||Vol 10, No 4 (Autumn 2022)|
|Steven Johnson Syndrome Norfloxacin Ciproflocaxin Fluroquinolones Adverse Drug Reaction|
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