The Many Faces of Purpura: Vancomycin-Induced Leukocytoclastic Vasculitis

Abstract

Leukocytoclastic vasculitis is a rare form of immune-mediated vasculitis that might be caused by infections or autoimmune diseases or might be precipitated by specific medications. We describe a 65-year-old patient, who was receiving vancomycin for a methicillin-sensitive Staphylococcus aureus permacath infection. Vancomycin was chosen due to medication non-adherence and the patient’s desire to receive antimicrobial therapy in conjunction with his scheduled dialysis sessions. The patient’s medical history was notable for untreated hepatitis C infection and end-stage renal disease, requiring hemodialysis three times a week. Vancomycin was administered during dialysis sessions. After one week of therapy, the patient developed bilateral lower extremity purpura. Skin biopsy was suggestive of leukocytoclastic vasculitis with an absence of intravascular thrombi. Serum cryoglobulins were negative, making cryoglobulinemia due to HCV infection unlikely. Following cessation of vancomycin therapy, the rash gradually disappeared with scarring in the form of post-purpuric hyperpigmentation. Despite its widespread use, vancomycin is a rare cause of leukocytoclastic vasculitis. Clinicians should keep in mind a wide range of differential diagnosis of bilateral lower extremity purpura as treatment differs depending on its underlying etiology.

Leukocytoclastic vasculitis caused by sulfamethoxazole‐trimethoprim

“…In our case, vancomycin was used for 6 weeks before it was de‐escalated to SMT. Vancomycin can also cause LCV, as evidenced by published reports 14–16 . However, in our patient, the rash appeared after 3 days of initiation of SMT.…”

Vancomycin-Induced Leukocytoclastic Vasculitis: A Rare Complication From a Commonly Used Medication

“…The most common clinical finding of LCV is the presence of a cutaneous non-blanching palpable purpura, although exclusive erythema, maculopapular lesions, or petechiae have also been noted in the literature [ 2 - 3 ]. Histological analysis of the cutaneous lesions in LCV typically shows sub-epidermal acantholysis with a dense inflammatory infiltrate predominantly composed of neutrophils, leading to a subsequent release of lysosomal enzymes causing a fibrinoid necrosis of the vasculature [ 4 - 5 ].…”

Ceftriaxone-induced leukocytoclastic vasculitis: a case report and literature review of antibiotic-induced leukocytoclastic vasculitis

“…A total of 60 published articles were included, comprising a total of 74 cases published between 1955 and 2021 (Table 1). 20,26,27,30 –86 Analyses of the reported cases of antibiotic-induced leukocytoclastic vasculitis revealed that it is associated with numerous classes of antibiotic, including penicillin (amoxicillin, amoxicillin-clavulanic acid, oxacillin), cephalosporins (cefazolin, cephalexin, cefuroxime, ceftriaxone, cefotaxime), fluoroquinolone (ciprofloxacin, levofloxacin, ofloxacin), macrolides (azithromycin, clarithromycin), vancomycin, teicoplanin, trimethoprim-sulfamethoxazole, dapsone, linezolid, pristinamycin, tigecycline, isoniazid, streptomycin, rifampin, ethambutol, and pyrazinamide.…”