Vancomycin leading to lupus flare in an elderly lady: a case report

Abstract

Elderly lady underwent right eye surgery for vitreous clot removal. 72 hours later, she complained of pain, redness and swelling in operated eye. Endophthalmitis was diagnosed. She was started on piperacillin/ tazobactam and vancomycin. Evisceration was required. Coagulase negative Staphylococci were isolated and vancomycin was continued postoperatively. She was discharged on home intravenous vancomycin therapy. Admitted one week later with painful oral ulcers, fever and diffuse erythmatous body rash. Vancomycin and other medications were stopped. Investigations revealed elevated double-stranded deoxyribonucleic acid and anti histone antibodies. Skin biopsy was suggestive of lupus rash. She was started on 60 mg of oral prednisone, improved dramatically and discharged to home.

Vancomycin Hypersensitivity Reaction Presenting with Extensive Oral Ulcerations

“…Whether involving fever and other clinical manifestations or not, this vancomycin hypersensitivity reaction type is thought to be immunologically-mediated [2,3]. One hypothesis argues this hypersensitivity reaction type is caused by immune-mediated peripheral neutrophil destruction and aberrant cytokine release [2,4,5]. Another hypothesis argues that, under certain circumstances, vancomycin is oxidized to a reactive metabolite that binds tissue macromolecules to form haptens, which stimulate T-cells to destroy neutrophils and promote other manifestations [2,6].…”

“…One patient developed necrotic oral mucosal lesions, fever, neutropenia, rash, and eosinophilia on vancomycin treatment day 15 [4]. The other patient had systemic lupus erythematosus (SLE) patient and developed fever, tachycardia, oral ulcers, and rapidly spreading rash after 3 weeks of vancomycin therapy [5]. The latter patient's clinical findings were attributed to an SLE flare because a skin biopsy showed direct immunofluorescence (DIF) findings suggestive of a lupus band.…”