A Rare Instance of Levofloxacin Induced Myoclonus

Abstract

An elderly man, 78-year-old (informed consent obtained from the patient), was admitted to the hospital, with complaints of difficulty in walking and brief shock like movements of all four limbs. The patient was a chronic smoker and alcoholic (for more than 40 years), with no prior comorbidities like diabetes mellitus, hypertension, renal issues or CNS disorders. Past history revealed that he had consulted doctors at other hospitals with complaints of cough with haemoptysis for which he was diagnosed to be a case of pulmonary tuberculosis and was initiated on 300 mg of isoniazid, 450 mg of rifampicin and 800 mg of ethambutol. Also, he was advised to continue this multidrug treatment for the next six months. However, after about a month, he developed numbness and tingling sensation, which was diagnosed to be peripheral neuropathy. As this peripheral neuropathy was suspected to be due to isoniazid, the drug was stopped and the patient was started on 500 mg of levofloxacin daily. Four days from the start of levofloxacin therapy, the patient had involuntary movements and on and off altered behaviour (clapping, hitting himself and altered speech). There was no history of loss of consciousness, urinary incontinence or burning sensation in the lower limbs. There was also no history of trauma, difficulty in swallowing or muscular pain.

Hemodialysis for treatment of levofloxacin‐induced neurotoxicity

“…Similar to our two cases, most previous reports establish advanced age and impaired kidney function as risk factors for levofloxacin‐induced neurotoxicity …”

“…A review of the literature identifies 24 case reports of levofloxacin‐induced neurotoxicity (Table ). Myoclonus, chorea and orofacial dyskinesia were the most frequently reported neurological adverse effects . In one case, levofloxacin administered orally at a daily dose of 500 mg for 4 days for tuberculosis resulted in the development of myoclonus in an elderly patient, prompting discontinuation of the antibiotic with resolution of symptoms after 3 days .…”

“…Myoclonus, chorea and orofacial dyskinesia were the most frequently reported neurological adverse effects . In one case, levofloxacin administered orally at a daily dose of 500 mg for 4 days for tuberculosis resulted in the development of myoclonus in an elderly patient, prompting discontinuation of the antibiotic with resolution of symptoms after 3 days . Similarly, oral levofloxacin administered at a dose of 500 mg twice daily for 3 days triggered reversible craniocervical dystonia in a patient with ESRD, which completely resolved 7 days after stopping the medication .…”

“…8,11,16 In one case, levofloxacin administered orally at a daily dose of Hemodialysis for levofloxacin-induced neurotoxicity Hemodialysis International 2019; 23:E40-E45 E41 500 mg for 4 days for tuberculosis resulted in the development of myoclonus in an elderly patient, prompting discontinuation of the antibiotic with resolution of symptoms after 3 days. 16 Similarly, oral levofloxacin administered at a dose of 500 mg twice daily for 3 days triggered reversible craniocervical dystonia in a patient with ESRD, which completely resolved 7 days after stopping the medication. 11 Furthermore, orofacial dyskinesia has been reported in an elderly woman with acute kidney injury 4 days after receiving levofloxacin 500 mg intravenously daily for diverticulitis.…”

“…19 Similar to our two cases, most previous reports establish advanced age and impaired kidney function as risk factors for levofloxacin-induced neurotoxicity. 8,10,11,15,16 The management of severe toxicity of fluoroquinolones is symptomatic and supportive, with a focus on drug discontinuation, treatment of seizures if they develop with intravenous benzodiazepines, and monitoring for QTinterval prolongation and torsade de pointes. While the prescribing information for levofloxacin states that in case of an acute over dose, the drug is not efficiently removed by hemodialysis or peritoneal dialysis, 4 , there are pharmacokinetic studies demonstrating that levofloxacin is dialyzable.…”