Levofloxacin-Induced Toxic Epidermal Necrolysis
Stevens-Johnson syndrome and toxic epidermal necrolysis (TEN) are mild-to-life-threatening adverse reactions that have been described after exposure to fluoroquinolones. No published reports, however, exist of exfoliative disease after treatment with levofloxacin. A 78-year-old woman with many medical problems, including chronic obstructive pulmonary disease, was treated with parenteral levofloxacin for community-acquired pneumonia. She was discharged with oral levofloxacin to complete an additional 3 days of treatment as an outpatient. Two days after completing this regimen, the patient developed a rash with blistering. The rash progressed to TEN in 7 days, and she was transferred to a burn treatment center. She was treated with fluid resuscitation, wound dressing, and antibiotics. Her condition improved, and she was discharged after 22 days. To our knowledge, this case is the first published report of levofloxacin-induced TEN.

Fluoroquinolones represent approximately 11% of antibiotics prescribed worldwide to treat outpatient infections such as urinary tract infections, lower respiratory tract infections, and bronchitis. The antimicrobial spectrum and high pulmonary tissue concentrations of the 6-fluoroquinolones make them particularly attractive for the treatment of hospital- and community-acquired lower respiratory tract infections. Adverse effects after treatment with 6-fluoroquinolones have been described, including anaphylaxis, seizures, drug-induced arrhythmias, hepatic injury, and Achilles tendon rupture. Exfoliative rashes, including toxic epidermal necrolysis (TEN), are less common reactions to antimicrobial agents but may be severe and life-threatening. Exfoliative rashes have been reported after treatment with most of the commercially available fluoroquinolones, and at least one report of exfoliative dermatitis associated with levofloxacin exposure has been reported to the manufacturer.

The newer fluoroquinolone analogs, such as gatifloxacin and moxifloxacin, have had the additional fluorines replaced with methoxy groups in an attempt to avoid metabolite-induced phototoxic reactions. The mechanism for exfoliative dermatitis (Stevens-Johnson syndrome [SJS] and TEN) appears to be activation of the immune system by 6-fluoroquinolones or their metabolites rather than direct toxic effects on keratinocytes.