Ciprofloxacin-induced Stevens-Johnson Syndrome with Grapefruit Juice Consumption: A Case Report

Abstract

We describe the case of a 49-year-old, otherwise healthy, Hispanic male who underwent an uncomplicated vasectomy and was treated prophylactically with a one-week course of ciprofloxacin. Two days after completing the antibiotic course, he developed a pruritic, blistering rash that covered 90% of his body surface area. Punch biopsy of the skin lesions confirmed the diagnosis of Stevens-Johnson syndrome (SJS). Upon further questioning, it was revealed that the patient had consumed approximately 32 ounces of grapefruit juice each of the seven days following his vasectomy. We hypothesized that the cytochrome P450 inhibitory effect of grapefruit juice had dramatically elevated systemic levels of ciprofloxacin, increasing the risk of developing SJS. Literature review revealed that ciprofloxacin is metabolized primarily by CYP1A2 with partial CYP3A4 metabolism, while grapefruit juice is strictly an enterocyte CYP3A4 inhibitor. To the authors’ knowledge, consumption of grapefruit juice has never been demonstrated to increase systemic levels of ciprofloxacin or of other fluoroquinolones. We conclude that either this is the first reported case of a grapefruit juice-ciprofloxacin interaction causing SJS, or that this is simply ciprofloxacin-induced SJS. Importantly, ciprofloxacin is not recommended by the American Urological Association for a routine vasectomy without risk factors for infection. We remind clinicians that inappropriately prescribed antibiotic prophylaxis for routine procedures can cause serious morbidity, including SJS, and should only be prescribed when indicated.

Together or Apart? Revealing the Impact of Dietary Interventions on Bioavailability of Quinolones: A Systematic Review with Meta-analyses

“…Grapefruit juice inhibits CYP3A4 enzymes in the gut, slowing down drug metabolism and potentially impacting the bioavailability of certain medications. Recently, Cravens et al described the case of a 49-year-old healthy male who experienced Stevens-Johnson syndrome (SJS) shortly after completing a prophylactic course of ciprofloxacin following a vasectomy [ 39 ]. The patient had consumed approximately 950 mL (32 oz) of grapefruit juice daily for seven days.…”

Linezolid and Ciprofloxacin-Induced SJS/TEN (Stevens-Johnson Syndrome/Toxic Epidermolysis Necrosis) Overlap in a Patient With Borderline Personality Disorder During a Single Hospital Stay: A Difficult Case to Manage

“…Our patient developed the first episode of SJS/TEN overlap after taking ciprofloxacin. We hypothesized that as the patient was using the tablet topiramate 50 mg for borderline personality disorder, it got metabolized by CYP3A4 (cytochrome 3A4) in the liver, which was potentially inhibited by ciprofloxacin [ 8 ], thereby causing an increase in the levels of antipsychotic topiramate. The combined effect of these two drugs increased the chances of the patient developing SJS/TEN.…”

“…This case report is unique in that the patient had a borderline personality disorder and experienced SJS/TEN twice due to the intake of distinct antimicrobial medication classes. Several cases of SJS/TEN due to ciprofloxacin have been reported in the literature [ 6 - 8 ]. However, only 63 linezolid-related SJS reports have been identified so far, affecting males and females equally [ 9 ].…”