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This document summarizes a case study of a 23-year-old male who experienced recurrent fixed drug eruptions from repeated use of different fixed-dose combinations containing fluoroquinolones and nitroimidazoles to self-treat diarrhea. Each time he took one of these combinations, he developed intensely itchy vesicular lesions all over his body within 30 minutes that healed with hyperpigmentation. Over the past few years, he experienced this reaction five times with different drug combinations, with increasing severity, demonstrating cross-sensitivity within the drug classes. No reaction occurred when using just metronidazole alone.

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Hafidh Khan
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54 views

Case Presentation: Go To

This document summarizes a case study of a 23-year-old male who experienced recurrent fixed drug eruptions from repeated use of different fixed-dose combinations containing fluoroquinolones and nitroimidazoles to self-treat diarrhea. Each time he took one of these combinations, he developed intensely itchy vesicular lesions all over his body within 30 minutes that healed with hyperpigmentation. Over the past few years, he experienced this reaction five times with different drug combinations, with increasing severity, demonstrating cross-sensitivity within the drug classes. No reaction occurred when using just metronidazole alone.

Uploaded by

Hafidh Khan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Fixed drug eruptions (FDE) are a distinct type of drug eruptions that appear as pruritic, well

circumscribed, round or oval-shaped, erythematous macules or edematous plaques, and


characteristically recur at the same sites upon re-exposure to the offending drug. They usually
resolve spontaneously with hyperpigmentation.1 The lesions after healing remain quiescent
and present on the skin, mucous membrane, or on both for prolonged periods as gray-brown
macules or plaques. Their number and severity may increase with repeated exposure.
Swelling and redness of the skin is typically seen within 30 minutes to 8 hours after suspected
drug exposure. Lesions are more commonly seen on extremities, genitals and perianal areas,
but they may appear on any location.1,2
FDEs are not uncommon and are seen with a host of drugs, including
nitroimidazoles2,3 fluoroquinolones4,5 and cross sensitivity and poly-sensitivity among
different members of the same pharmacological class do exist.2,6 It is generally believed that if
an individual develops FDEs to a particular drug, exposure to structurally similar drugs from
the same pharmacological group should preferably be avoided.2
Diarrheal disorders are quite common in all age groups7 and are mostly of infective
origin.8 The tendency to self-treat episodes of diarrhea among adults seems to be
widespread,9 and people often indulge in self medication. This is not surprising, particularly
in the backdrop of the irrational dispensing practices that prevails in India allowing easy
availability of prescription medicines without a prescription. Different fixed dose
combinations (FDC) consisting of an antiprotozoal and an antibacterial, are marketed in India
for the treatment of diarrhea. While there is little evidence to justify the rationale for their use
in diarrhea, they certainly expose the patients to higher risks of adverse reactions and increase
emergence of drug resistance.8
Here we present a case of self-treatment induced repeated episodes of recurrent fixed drug
eruptions secondary to the use of different fixed dose combinations of fluoroquinolone-
nitroimidazole.
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Case Presentation
A 23-year-old male, college student, presented with multiple, round-to-oval, well-defined,
hyperpigmented cutaneous patches of different dimensions all over the body, particularly
more on the neck, trunk, forearms, and dorsum of the hands and legs (figures 1--4).4). Some
of these lesions developed about one month back when he had taken an FDC of ciprofloxacin
(500 mg) and tinidazole (600 mg) for acute gastroenteritis. Within 30 minutes of intake of the
first dose, multiple vesicular lesions started to appear all over the body that were intensely
itchy, and that on scratching turned within a few hours into fluid-filled purplish vesicles with
burning sensation. He remained afebrile with no other major complaint. He took cetirizine
(10 mg) for one week. The lesions gradually healed up in the next 10 days, leaving behind
dark grey hyperpigmented lesions, which persisted at the time of his visit to us. The rest of
the similar dark patches with which the patient presented were, as the history revealed,
sequelae of exposure to FDCs of different fluoroquinolones and nitroimidazoles several times
in the past few years. The medically lay patient indulged in self-medication whenever he
suffered loose motion or diarrhea and he preferred taking similar oral FDCs combining a
fluoroquinolone and a nitroimidazole. He experienced recurring episodes of similar
cutaneous reactions each time he consumed such FDCs, on five such occasions (including the
current one) in the last 2-3 years. Interestingly, each time he changed the molecules of the
FDC (with ciprofloxacin or ofloxacin as fluoroquinolone, and tinidazole or ornidazole as
nitroimidazole), expecting to avoid the cutaneous reaction. But, rather he experienced an
increase in the number of sites and in size of the cutaneous lesions with repeated exposure to
the qualitatively similar FDCs. As soon as the rashes appeared, he discontinued the treatment.
Further probing revealed that sometimes he used only metronidazole instead of a FDC and
there was no cutaneous reaction.

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