Correspondence

Achilles Tendinitis and Tendon Rupture Due to Fluoroquinolone Antibiotics

N Engl J Med 1994; 331:748September 15, 1994

Article

To the Editor:

Tendinitis and tendon rupture are unusual and unexpected side effects of drugs1,2. An 85-year-old man had been treated for polymyalgia rheumatica with prednisone. His condition improved in the next three months, and the dose of prednisone was reduced to 15 mg per day. Two weeks later a urologist prescribed enoxacin (two 200-mg tablets twice a day) for a urinary tract infection. On the seventh day of enoxacin therapy, pain developed in both calves radiating to the heels. The patient noted mild swelling in the lower extremities. On examination a week later he had difficulty walking because of pain in his lower legs. There was marked tenderness to palpation in both Achilles tendons. The ankle reflexes were normal. Fluoroquinolone-induced bilateral Achilles tendinitis was suspected, and nabumetone was prescribed. The patient continued to have difficulty walking, and twelve days later a defect was palpated in the right Achilles tendon. Magnetic resonance imaging showed a complete rupture of the right Achilles tendon approximately 3 cm above the calcaneus. The patient was treated with a brace on the right ankle, with improvement in pain. The pain in the left calf and Achilles tendon resolved.

Fluoroquinolone antibiotics have been associated with Achilles tendinitis and rupture in reports from Europe and New Zealand1,2. As of 1992 more than 40 cases had been reported in France. This unusual side effect has not been widely recognized in the United States and is not mentioned in the Physicians' Desk Reference. Physicians should be aware of this potential complication.

Kent A. Huston, M.D.
4330 Wornall St., Kansas City, MO 64111

2 References

1. 1

   Ribard P, Audisio F, Kahn MF, et al. Seven Achilles tendinitis including 3 complicated by rupture during fluoroquinolone therapy. J Rheumatol 1992;19:1479-1481
   Web of Science | Medline

2. 2

   Lee WT, Collins JF. Ciprofloxacin associated bilateral Achilles tendon rupture. Aust N Z J Med 1992;22:500-500
   Medline

Citing Articles (24)

Citing Articles

1. 1

   Brian Petersen, Jeff Fitzgerald, Ken Schreibman. (2010) Musculotendinous Magnetic Resonance Imaging of the Ankle. Seminars in Roentgenology 45:4, 250-276
   CrossRef

2. 2

   Judith Sendzik, Mehdi Shakibaei, Monika Schäfer-Korting, Hartmut Lode, Ralf Stahlmann. (2010) Synergistic effects of dexamethasone and quinolones on human-derived tendon cells. International Journal of Antimicrobial Agents 35:4, 366-374
   CrossRef

3. 3

   Adam Mor, Michael H. Pillinger, Robert L. Wortmann, Hal J. Mitnick. (2008) Drug-Induced Arthritic and Connective Tissue Disorders. Seminars in Arthritis and Rheumatism 38:3, 249-264
   CrossRef

4. 4

   Abdulrahman Mohammed Al-Amri. (2008) Corneal Perforation Associated With Topically Applied Gatifloxacin. Cornea 27:3, 370-371
   CrossRef

5. 5

   Eduardo Barge-Caballero, María G. Crespo-Leiro, María J. Paniagua-Martín, Javier Muñiz, Carmen Naya, Alberto Bouzas-Mosquera, Pablo Piñón-Esteban, Raquel Marzoa-Rivas, Pablo Pazos-López, Guillermo C. Cursack, José J. Cuenca-Castillo, Alfonso Castro-Beiras. (2008) Quinolone-related Achilles Tendinopathy in Heart Transplant Patients: Incidence and Risk Factors. The Journal of Heart and Lung Transplantation 27:1, 46-51
   CrossRef

6. 6

   Sanjay V. Raikar, R. Kanvinde, Patanjali Chaturvedi. (2006) Spontaneous bilateral Achilles tendon rupture associated with Levofloxacin. European Journal of Orthopaedic Surgery & Traumatology 16:1, 86-88
   CrossRef

7. 7

   Giovanni Corrao, Antonella Zambon, Lorenza Bert??, Anna Mauri, Valentina Paleari, Camillo Rossi, Mauro Venegoni. (2006) Evidence of Tendinitis Provoked by Fluoroquinolone Treatment. Drug Safety 29:10, 889-896
   CrossRef

8. 8

   C Yu, BM Giuffre. (2005) Achilles tendinopathy after treatment with fluoroquinolone. Australasian Radiology 49:5, 407-410
   CrossRef

9. 9

   Sujata M. Bhavnani, David R. Andes. (2005) Gemifloxacin for the Treatment of Respiratory Tract Infections: In Vitro Susceptibility, Pharmacokinetics and Pharmacodynamics, Clinical Efficacy, and Safety. Pharmacotherapy 25:5, 717-740
   CrossRef

10. 10

    Irene Blanco, Stephan Kr??henb??hl, Raymond G Schlienger. (2005) Corticosteroid-Associated Tendinopathies. Drug Safety 28:7, 633-643
    CrossRef

11. 11

    Ana Szarfman, Joseph M. Tonning, P. Murali Doraiswamy. (2004) Pharmacovigilance in the 21st Century: New Systematic Tools for an Old Problem. Pharmacotherapy 24:9, 1099-1104
    CrossRef

12. 12

    Umberto Fama, Silvio Irace, Riccardo Frati, Federico de Gado, Nicol?? Scuderi. (2004) IS IT A REAL RISK TO TAKE CIPROFLOXACIN?. Plastic and Reconstructive Surgery 114:1, 267
    CrossRef

13. 13

    Graeme A Pollock, Penelope A McKelvie, Daniel J McCarty, Jacinta F White, Peter LT Mallari, Hugh R Taylor. (2003) In vivo effects of fluoroquinolones on rabbit corneas. Clinical and Experimental Ophthalmology 31:6, 517-521
    CrossRef

14. 14

    Y. Khaliq, G. G. Zhanel. (2003) Fluoroquinolone-Associated Tendinopathy: A Critical Review of the Literature. Clinical Infectious Diseases 36:11, 1404-1410
    CrossRef

15. 15

    Roberto Leone, Mauro Venegoni, Domenico Motola, Ugo Moretti, Valentina Piazzetta, Alfredo Cocci, Domenico Resi, Federico Mozzo, Giampaolo Velo, Liliana Burzilleri, Nicola Montanaro, Anita Conforti. (2003) Adverse Drug Reactions Related to the Use of Fluoroquinolone Antimicrobials. Drug Safety 26:2, 109-120
    CrossRef

16. 16

    M. W. Butler, J. F. Griffin, W. R. Ouinlan, T. J. McDonnell. (2001) Quinolone-associated tendonitis: a potential problem in COPD?. Irish Journal of Medical Science 170:3, 198-199
    CrossRef

17. 17

    Paul D. Van Der Linden, Eugne P. Van Puijenbroek, Johan Feenstra, Bas A. In ?T Veld, Miriam C. J. M. Sturkenboom, Ron M. C. Herings, Hubert G. M. Leufkens, Bruno H. Ch. Stricker. (2001) Tendon disorders attributed to fluoroquinolones: a study on 42 spontaneous reports in the period 1988 to 1998. Arthritis & Rheumatism 45:3, 235-239
    CrossRef

18. 18

    Peter Lloyd T. Mallari, Daniel J. McCarty, Mark Daniell, Hugh Taylor. (2001) Increased incidence of corneal perforation after topical fluoroquinolone treatment for microbial keratitis. American Journal of Ophthalmology 131:1, 131-133
    CrossRef

19. 19

    Van Der Linden, Van De Lei, Nab, Knol, Stricker. (1999) Achilles tendinitis associated with fluoroquinolones. British Journal of Clinical Pharmacology 48:3, 433-437
    CrossRef

20. 20

    P. Kannus, A. Natri. (1997) Etiology and pathophysiology of tendon ruptures in sports. Scandinavian Journal of Medicine & Science in Sports 7:2, 107-112
    CrossRef

21. 21

    G. Kempka, H.J. Ahr, W. Rüther, G. Schlüter. (1996) Effects of fluoroquinolones and glucocorticoids on cultivated tendon cells in vitro. Toxicology in Vitro 10:6, 743-754
    CrossRef

22. 22

    (1995) More on Fluoroquinolone Antibiotics and Tendon Rupture. New England Journal of Medicine 332:3, 193-193
    Full Text

23. 23

    P. Gillet, A. Blum, D. Hestin, J. Pourel, C. Pierfitte, D. Mainard, M. Kessler, P. Netter. (1995) Magnetic resonance imaging may be an asset to diagnose and classify fluoroquinolone-associated Achilles tendinitis. Fundamental & Clinical Pharmacology 9:1, 52-56
    CrossRef

24. 24

    &NA;. (1994) Enoxacin. Reactions Weekly &NA;:520, 6
    CrossRef