Biopsy-proved acute tubulointerstitial nephritis and toxic epidermal necrolysis associated with vancomycin.
A 70-year-old man receiving vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) abscess developed a drug-induced hypersensitivity reaction with rash, eosinophilia, and acute renal failure requiring dialysis. Renal biopsy revealed diffuse and marked interstitial and tubular infiltration by mononuclear cells and eosinophils; acute tubulointerstitial nephritis (TIN) was diagnosed. The rash progressed to erythema multiforme major after rechallenge with vancomycin in the setting of MRSA peritoneal catheter-related peritonitis and then to fatal toxic epidermal necrolysis in the setting of steroid taper and persistent serum vancomycin levels. This case further implicates vancomycin as a drug that infrequently can cause severe acute TIN and exfoliative dermatitis. When a renally excreted drug such as vancomycin is administered, serum drug levels should be serially monitored and high-dosage steroids be maintained or tapered slowly until serum drug levels become undetectable.
Hsu
S I
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Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, USA. mdchsus@nus.edu.sg
D000208:Acute Disease; D000368:Aged; D000900:Anti-Bacterial Agents / Q000009:adverse effects* / Q000627:therapeutic use; D004342:Drug Hypersensitivity / Q000473:pathology*; D006801:Humans; D008297:Male; D009395:Nephritis, Interstitial / Q000139:chemically induced* / Q000473:pathology*; D016659:Psoas Abscess / Q000150:complications / Q000188:drug therapy; D013203:Staphylococcal Infections / Q000150:complications / Q000188:drug therapy; D013262:Stevens-Johnson Syndrome / Q000473:pathology*; D014640:Vancomycin / Q000009:adverse effects* / Q000627:therapeutic use
D000900:Anti-Bacterial Agents; D014640:Vancomycin