The Fluoroquinolone Toxicity Research Foundation

 
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Tendon Damage Research                  See downloads for: Adobe Files



Re: Spontaneous rupture of Achilles tendon and fluoroquinolones


Email Hari Polenakovik:
hpolenakovik@pol.net

EDITOR:

The article by Abdusalam Mousa et al on spontaneous rupture of Achilles tendon: missed presentation of Cushing’s syndrome, failed to mention tendon rupture as a complication of fluoroquinolone (FQ) use.1

FQ are synthetic antibiotics with good efficacy against infections caused by gram -positive and gram negative organisms.2 Musculoskeletal side effects (arthralgias, arthropathy, tendinitis and tendon rupture) are rare but well documented complications of FQ therapy.2-5 There have been over 200 reported cases in the literature of FQ associated tendinitis and tendon rupture, mostly involving the Achilles tendon.2,5 Pefloxacin and enoxacin are most common offending agents, but cases implicating newer FQ (ciprofloxacin and levofloxacin) can also be found in the literature.2-5

Tendon rupture can occur from 2 to 42 days after the start of therapy.3 Relevant risk factors include concomitant corticosteroid use (in close to half of the reported cases), chronic renal failure and advanced age. 2-5 The latter two probably reflect decreased clearance of these drugs.

Magnetic resonance imaging is helpful in diagnosing suspected FQ induced tendinitis and tendon rupture and may allow planning of therapy.2,4 Therapy includes withdrawal of the FQ and rest of the affected extremity, use of splints, occasional bellow-the-knee casting, and rarely surgical repair of the tendon.2,3 Patients presenting with new onset tendon discomfort or swelling should be questioned about recent use of FQ along with evaluation for symptoms and signs of systemic diseases (Cushing's disease, rheumatoid arthritis systemic lupus erythematosus, gout etc) associated with tendon rupture.

1/ Mousa A, Jones S, Toft A, Perros P. Spontaneous rupture of Achilles tendon: missed presentation of Cushing’s syndrome. BMJ 1999; 319:560-561.

2/ Harrel RM. Fluoroquinolone-induced tendinopathy: what do we know? South Med J 1999; 92:622-625,1999.

3/ Szarfman A, Chen M, Blum M. More on fluoroquinolone antibiotics and tendon rupture. N Engl J Med 1995; 332: 193.

4/ Pierfitte C, Gillet P, Royer RJ. More on fluoroquinolone antibiotics and tendon rupture. N Engl J Med 1995; 332: 193.

5/ Lewis JR, Gums JG, Dickensheets DL. Levofloxacin-induced bilateral Achilles tendinits. Ann Pharmacother 1999; 33:792-795.

Hari Polenakovik, MD
Clinical Instructor
Wright State University – Department of Medicine, 128 East Apple Street, CHE 2nd floor, Dayton, OH 45419 USA
Email: hpolenakovik@pol.net

Sylvia Polenakovik, MD
Clinical Instructor
Wright State University – Department of Medicine, 128 East Apple Street, CHE 2nd floor, Dayton, OH 45419 USA