Pathogenesis of Tendon Rupture Secondary to Fluoroquinolone Therapy

Abstract

Tendon rupture related to trauma and corticosteroid injection, in and about tendon insertion sites, is well documented in the literature. Rupture of tendon after fluoroquinolone therapy has been identified in the recent past. Both short- and long-term courses of antibiotic treatment with fluoroquinolone may precipitate alteration in tendon matrix leading to tendinopathy with subsequent rupture. The pathogenesis of tendon rupture secondary to fluoroquinolone therapy is presented.

Methicillin-resistant Staphylococcus aureus: an overview for manual therapists

“…[86][87][88] Age greater than 60 years, sex, use of corticosteroids, diabetes, and strength-training and aerobic-conditioning activities are associated with higher rates of fluoroquinolone-induced tendinopathy. 89 This tendinopathy may manifest in both the lower and upper extremities; range from minor discomfort to frank tendon rupture; or become symptomatic within hours of the initial dose, but typically a week after the start of therapy 90 ; and may persist for months following cessation of medication therapy. 78,91 Awareness of medication use should influence manual therapists' clinical decision making, such as when not to engage in strenuous activity or deep tissue mobilization.…”

Fluoroquinolones and Tendinopathy: A Guide for Athletes and Sports Clinicians and a Systematic Review of the Literature

“…1 The pathways underpinning the tenotoxic effects of fluoroquinolones are unclear, 18 but 3 main mechanisms have been proposed: ischemia, degradation of the tendon matrix, and adverse alteration of tenocyte activity. 19 Matrix metalloproteinases are enzymes with degrading properties that are important in the homeostasis and response to injury of tendon tissue. 20,21 Fluoroquinolones facilitate expression of matrix metalloproteinases in tendon tissue 22 ; ciprofloxacin in particular has been shown to increase the expression of matrix metalloproteinase-3 in human Achilles tendonderived cells and to reduce collagen synthesis via inhibition of tenocyte proliferation.…”

A rare case of ciprofloxacin-induced bilateral rupture of the Achilles tendon

“…In animal models ciprofloxacin and pefloxacin were the two most tenotoxic fluoroquinolones;7 this study noted that the mechanism of tendon damage by was via cell membrane damage and tissue necrosis.…”

“…The sex-related ratio of fluoroquinolone-induced tendon side effects is 4:1 with a male preponderance 7. Achilles tendon rupture is said to be relatively uncommon,5 making this case of bilateral rupture in a female a rare clinical presentation.…”

“…By far the tendon most affected in the majority of cases is the Achilles tendon;6 other regions such as the flexor tendons of the hand, the rotator cuff and the quadriceps are affected to a lesser degree 3. Disorders of the Achilles encompass a variety of diagnoses in the literature such as tendinitis, tendinopathy and rupture,3 it is felt that a blanket term of “tendinopathy” should be used as histological and imaging show that not all affected tendons have an associated inflammatory response7 Ribard and colleagues8 hypothesised that the greater weight-bearing demand placed on the Achilles tendon is the cause of high prevalence of its drug-induced tendinopathy. Despite a growing body of literature regarding the tenotoxic properties of fluoroquinolones cases of Achilles tendon rupture are rare5 and bilateral rupture even more so 9…”