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JNEPHROL 2001; 14: 431-432

Ciprofloxacin-associated Achilles tendon rupture in a hemodialysis patient

Moreno Malaguti, Luigi Triolo, Marco Biagini - Department of Nephrology, San Paolo Hospital, Civitavecchia - Italy

Introduction

Fluoroquinolones (FQ) are relatively safe and effective antibacterial agents. The most common adverse effects involve the gastrointestinal tract, skin and central nervous system, and are mainly mild and reversible (1). Tendinitis and rupture, usually of the Achilles tendon (AT), are rare class-effects of FQ, most frequently reported with pefloxacin and ofloxacin (1, 2).
The pathogenesis of these lesions remains unknown and is probably multifactorial. However, the sudden onset, occasionally after a single dose, suggests the possibility of direct toxicity leading to an ischemic process (3, 4).
Ageing and corticosteroid use are well recognized predisposing factors. End-stage renal disease has been implicated, too (5). Tendinitis is considered a common complication of renal transplantation (6, 7), but few data have been reported about dialysis patients (8-10), particularly in the nephrologic literature.
We report a case of spontaneous AT rupture associated with ciprofloxacin in a hemodialyzed patient.

Case report

A 59-year-old patient with end stage renal failure, secondary to hypertensive nephrosclerosis, was started on hemodialysis on July 1998. The patient had a medi-cal history of lung cancer, treated in 1992 with lobectomy, followed by radio and chemotherapy. On July 2000, he was commenced on oral ciprofloxacin, 500 mg daily for 10 days, because of an acute respiratory infection. Two days after the end of the antibiotic therapy, he developed pain in the right AT. In spite of absolute rest, three days later, he felt a snap in his right AT. Orthopedic (positive Thompson's test) and ultrasonographic evaluation confirmed tendon rupture, which required surgical repair. One month later, full function of the tendon was recovered.

Discussion

AT pain and rupture has been described as an uncommon adverse effect of FQ treatment. The pathophysiological relationship is still unclear. Necrosis with neovascularization, interstitial edema and degenerative lesions without inflammatory cell infiltrate have been reported, suggesting the role of ischemic factors (5). Incubation of canine Achilles tendon fibroblasts with ciprofloxacin resulted in a significant decrease in cell proliferation compared with control cells and showed that ciprofloxacin stimulates matrix-degrading protease activity from fibroblasts (11).
Tendinopathy has been associated with renal disease, and chronic corticosteroid use - particularly in kidney transplant patients - (6,7), amyloidosis(8) and secondary hyperparathyroidism (12) have been considered in the pathogenesis.
Our patient showed no clinical evidence of amyloidosis and an intact PTH level of 174 pg/ml. The dose of ciprofloxacin was higher than that usually suggested in end-stage renal failure. However, similar or higher doses have been used in CAPD patients with a low incidence of adverse effects (13).
Recent reports (1,5) highlight the crucial role of some predisposing conditions for FQ associated tendinitis. Therefore, since the use of FQ is becoming more frequent, the prescription should be carefully considered, and the dosage accurately managed, in subjects with well known risk factors, such as nephropathic patients.
Moreover, in view of the potential muscoloskeletal side effects of FQ, a strict surveillance is recommended in order to detect early signs of tendinopathy and avoid the risk of tendon rupture.

Reprint requests to: M. Malaguti, M.D. - Department of Nephrology San Paolo Hospital Civitavecchia, Italy

References

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9. Hofmann GO, Weber T, Lob G. Tendon rupture in chronic kidney insufficiency:"uremic tendonopathy"? A literature-supported documentation of three cases. Chirurg 1990; 61: 434-7. PMID: 2194758
10. Spencer JD. Spontaneous rupture of tendons in dialysis and renal transplant patients. Injury 1988; 19: 86-8. PMID: 3058609
11. Williams RJ III, Attia E, Wickiewicz TL, Hannafin JA. The effect of ciprofloxacin on tendon, paratenon, and capsular fibroblast metabolism. Am J Sports Med 2000; 28: 364-9. PMID: 10843129
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Received: November 22, 2000 Accepted: January 23, 2001



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