Images in Clinical Medicine

Quinolone-Associated Rupture of the Achilles' Tendon

Harsha Vyas, M.D., and Guha Krishnaswamy, M.D.

N Engl J Med 2007; 357:2067November 15, 2007

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An 81-year-old woman with rheumatoid arthritis, Sjögren's syndrome, and hypertension presented with swelling and pain in the area of the left heel, which had developed suddenly a week after a short course of levofloxacin for acute bronchitis. She reported neither trauma to the area nor any excessive physical activity before the pain began. Examination revealed an ecchymotic area around the left posterior heel and a moderately swollen calf. A defect was palpable in the lateral side of the Achilles' tendon; the medial side was still intact. Movement of the ankle was limited by severe pain. Magnetic resonance imaging (MRI) of the ankle revealed a near-full-thickness rupture of the Achilles' tendon (Panel A, arrows). The patient's ankle was immobilized in a short leg cast for 2 months. After removal of the cast, a repeat MRI scan showed nearly complete healing of the ruptured tendon (Panel B, arrows), and since then, the patient has been walking without limitation. Quinolones may facilitate the enhanced expression of matrix metalloproteinases in tissue, which in turn causes tendon injury and is most common in the elderly and in persons taking corticosteroids.

Harsha Vyas, M.D.
Guha Krishnaswamy, M.D.
Wake Forest University School of Medicine, Winston-Salem, NC 27157-1082
dr_harshavyas@yahoo.com

Citing Articles (7)

Citing Articles

1. 1

   Tolga Turker, Joseph E. Kutz. (2011) Can oral levofloxacin cause of flexor digitorum profundus rupture?. Medical Hypotheses 77:4, 696-697
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2. 2

   Akihiko Kato, Sayaka Ishigaki, Hideo Yasuda. (2011) Levofloxacin-associated Achilles tendinitis in a patient with chronic kidney disease stage 5. Clinical and Experimental Nephrology 15:2, 318-319
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3. 3

   C.H. Fürstenberg, B. Wiedenhöfer, C. Putz, I. Burckhardt, S. Gantz, K. Kleinschmidt, K. Schröder. (2010) Mit Gentamicin oder Levofloxacin gesättigter Kollagenhydroxyapatit (Healos®). Der Orthopäde 39:4, 437-443
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   Ralf Stahlmann, Hartmut Lode. (2010) Safety Considerations of Fluoroquinolones in the Elderly. Drugs & Aging 27:3, 193-209
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   Judith Sendzik, Hartmut Lode, Ralf Stahlmann. (2009) Quinolone-induced arthropathy: an update focusing on new mechanistic and clinical data. International Journal of Antimicrobial Agents 33:3, 194-200
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   Françoise Van Bambeke, Paul M. Tulkens. (2009) Safety Profile of the Respiratory Fluoroquinolone Moxifloxacin. Drug Safety 32:5, 359-378
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   (2008) Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiology and Drug Safety 17:5, i-xvi
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