Polymyxin B-Induced Diffuse Cutaneous Hyperpigmentation

Abstract

We present a rare case of Polymyxin B-induced diffused cutaneous skin hyperpigmentation in a 65-year-old elderly male of Indian origin. This patient had initially presented in the emergency with shortness of breath and low grade intermittent fever for last three months. He was also suffering from persistent productive cough and occasional haemoptysis for same duration. He was a known case of Chronic Obstructive Pulmonary Disease (COPD) for last 3 years and was on oral and inhalational medications.No past history of tuberculosis, significant weight loss, malignancy or cardiac disease could be elicited. Patient was non-smoker, non-alcoholic with no known history of any drug abuse. He was provisionally diagnosed to be in a state of acute exacerbation of COPD with left lower lung pneumonic consolidation and right-sided small pneumothorax.Laboratory investigations revealed: haemoglobin 12.7g/dl, Total Leukocyte Count (TLC) 10,400 with neutrophils 85%, lymphocyte 12%, random plasma glucose levels 156mg/dl, creatinine 0.6mg/ dl, bilirubin 0.9mg/dl, ALT 45IU. Arterial blood gas report showed: pH(7.43), pCO 2 (49.3), pO 2 (62.6), HCO 3 (32.5), SpO 2 (86%) (room air), Na + (130), K + (4). Echocardiogram suggested good preserved ventricular systolic function (ejection fraction 56%) with no regional wall motion abnormality, grade-I diastolic dysfunction with mild tricuspid regurgitation. Chest skiagram showed a thick walled cavity on left side, basal consolidations and increased peri-hilar translucency; sputum was negative for Acid Fast Bacilli (AFB) and Cartridge Based Nucleic Acid Amplification Test (CBNAAT) excluding pulmonary tuberculosis.On examination, blood pressure was 100/70mmHg, pulse rate 110/ min, JVP not raised, trachea shifted to left, poor bilateral air entry into lungs and bilateral severe wheeze.Patient was initially started on Fixed Dose Combination (FDC) of Piperacillin-Tazobactum (4.5gm intravenous thrice daily) and later upgraded to Meropenem (1gm thrice daily). Concurrent nebulization with Levo-Salbutamol (2 inhalations; 90mcg 6 hourly) and Ipratropium Bromide (2 inhalations; 36mcg 6 hourly), intravenous injection hydrocortisone (2mg/kg 6 hourly) were also initiated to maintain desired pO2 and SpO 2 .

Polymyxin B‐induced skin hyperpigmentation

“…PMB‐iH has been reported in the pediatric population, likely due to slower renal‐drug clearance rate in younger patients, which results in higher drug levels 5 . Presumably, patients who have renal‐insufficiency would be at more risk of developing PMB0‐iH 6 . However, this is unlikely an exacerbating factor of PMB‐iH in our patient due to her normal renal function post‐transplant.…”

“…More men and darker‐skinned patients (Fitzpatrick scale IV as opposed to I‐III) are affected (Table 1). 3,7‐9 Although some patients developed diffuse hyperpigmentation, 10 others had limited skin discoloration to photo‐exposed areas such as the face and neck 6,8 . According to a recent cohort study of 60 patients with gram‐negative infection who received 14‐day course of PMB, hyperpigmentation was observed by the 3rd day of treatment and improved gradually upon medication discontinuation.…”

Polymyxin B-induced skin hyperpigmentation: a rare case report and literature review

“…et al reported two suspected cases in 2007 for the first time [ 7 ]. A patient who suffered from MDR-KP infection was found with SH after treated by intravenous PMB for 4 days, according to the description by Lahiry S. et al [ 8 ]. Besides, there were several cases in neonates and infants as well.…”

Drug-Induced Hyperpigmentation: Review and Case Series

“…11,12 Isolated cases of hyperpigmentation due to levofloxacin have been described, although in isolated cases and long-term treatment regimens, or due to polymyxin, an antibiotic used primarily for resistance against Gram-negative germs, or to tigecycline, a new glycylcycline antibiotic. [13][14][15][16] .…”