Nafcillin-Induced Bullous Skin Eruption with Granulocytopenia in a Patient with End-Stage Renal Disease

Abstract

Nafcillin is an antibiotic used for infections due to penicillin-resistant Staphylococcus aureus. In general, the adverse reactions to nafcillin have not been frequent and serious. We report here a new type of adverse reaction to nafcillin in a patient with end-stage renal disease in whom nafcillin caused the unexpected complication of bullous drug eruption and subseqent neutropenia. Three weeks after the start of intravenous nafcillin for the treatment of peritoneal dialysis peritonitis, the patient developed blisters on his right ankle. These became progressive and widespread, with bullae affecting most of the body surface. In addition, neutropenia developed three days after the appearance of bullous skin lesions. Spontaneous recovery of skin lesions and neutropenia was observed after the withdrawal of naficillin. When treating patients with chronic renal failure, physicians should be aware of these rare but potentially severe adverse reactions.

A Review of β-Lactam–Associated Neutropenia and Implications for Cross-reactivity

“…Following β-lactam–induced neutropenia, only 3 of 27 (11%) patients experienced persistence or recurrence of neutropenia following substitution to or future rechallenge with a β-lactam from a separate class. 10,12,19,25-28,33,37,47,50,51,53,58,65,68,78-82…”

“…Following βlactam-induced neutropenia, only 3 of 27 (11%) patients experienced persistence or recurrence of neutropenia following substitution to or future rechallenge with a β-lactam from a separate class. 10,12,19,[25][26][27][28]33,37,47,50,51,53,58,65,68,[78][79][80][81][82] Cross-reactivity between β-lactams can occur through either the β-lactam ring itself, the class-specific ring, or side chains. The R1 side chain comes off the β-lactam ring, and penicillins only have the 1 side chain.…”

“…Following β-lactam–induced neutropenia, the risk of sustained or relapsed neutropenia with substitution to a β-lactam from a separate class appears to be low at approximately 10% based on the available case reports. 10,12,19,25-28,33,37,47,50,51,53,58,65,68,78-82 Thus, this strategy can serve as a useful and viable option when close laboratory monitoring is feasible and the benefits of continued β-lactam therapy outweigh the risks.…”

Doxepin‐induced bullous pemphigoid‐like drug eruption

“…There are some reports in the literature regarding bullous pemphigoid-like skin eruption following the administration of drugs like ibuprofen, nafcillin and nicotinamide. [3][4][5] However, reports in the literature regarding doxepin-induced bullous eruptions are limited. There is a case of bullous pemphigoid (BP) induced by penicillin which demonstrates subepidermal splitting in the microscopic evaluation and linear depositions in DIF examination.…”