Rifampicin induced shock during re-exposure for treatment of latent tuberculosis

Abstract

We present a case of a young Asian female with rheumatoid arthritis who received latent tuberculosis infection (LTBI) treatment prior to treatment with a biologic agent, and developed shock with resistant hypotension on re-exposure to rifampicin. We discuss the epidemiology, pathophysiology and management of rifampicin induced shock, concluding that clinicians should be aware of this rare, but potential adverse effect, and be aware that adverse reactions to rifampicin are more frequent during re-exposure or longer dosing interval regimes. The evidence for desensitisation following such a reaction is lacking and this approach is not currently recommended. We would suggest close collaboration between specialties prescribing immunosuppression and the tuberculosis team when LTBI treatment is required after a reaction, with patient involvement to discuss the risks and benefits of treatment options.

Acute reversible fulminant hepatitis associated with rifampicin

“…Urticaria and anaphylaxis may occur through IgE mediated mechanism [9]. Rifampicin, in vitro also showed vasodilatory effects caused by histaminergic upregulation and increased synthesis of nitric oxide [8]. Other mechanisms known to play a role in rifampicin induced hepatitis are oxidative metabolism, genotypes of cytochrome p450, 2E1, glutathione S-transferase M1, and N-acetyl transferase [9].…”

“…Even a single dose of rifampicin can induce sensitization and result in immunoallergic reactions on a repeat exposure [7]. Many mechanisms have been proposed for rifampicin hypersensitivity causing multiorgan involvement and shock, such as Type 1-4 hypersensitivity reactions, combined hypersensitivity pathways, IgG-and IgM-mediated cytotoxic immune response [3,8]. Urticaria and anaphylaxis may occur through IgE mediated mechanism [9].…”

Syndrome pseudogrippal avec choc induit par la rifampicine chez une patiente atteinte d’infection tuberculeuse

“…Les symptômes durent habituellement 8 heures et comprennent souvent de la fièvre, des frissons, des malaises, des céphalées et des arthralgies. En cas de reprise d'un traitement interrompu en raison d'une réaction indésirable à un médicament, une hypotension et un choc peuvent survenir à de rares occasions, et disparaître en 24 heures dans la plupart des cas [1][2][3][4][5][6] . La terminologie employée dans la littérature scientifique varie; nous qualifions ce tableau clinique grave de syndrome pseudogrippal avec choc induit par la rifampicine.…”

Rifampin-induced flu-like syndrome with shock in a patient with tuberculosis infection

“…When treatment is resumed after stopping because of adverse drug reactions, patients may uncommonly develop hypotension and shock, which generally resolve within 24 hours. [1][2][3][4][5][6] The terminology in the literature is inconsistent; we refer to this severe clinical presentation as rifampin-induced flu-like syndrome with shock.…”