Case Presentation:
A 59 year old African American male being treated for bilateral lower extremity deep vein thromboses, heparin‐induced thrombocytopenia, acute kidney injury and fever was administered intravenous vancomycin and piperacillin‐tazobactam for suspected health care acquired pneumonia. Other medications included warfarin and enoxaparin. On antibiotic day 1, the patient developed a pruritic rash of erythematous papules on the back, buttocks, and periorbital and oral areas, including the dorsum of the tongue and the oral mucosa. A penicillin hypersensitivity reaction was suspected and piperacillin‐tazobactam was discontinued on day 2. By day 5, tense vesicles and bullae with erythematous bases developed predominantly on the trunk, arranged in an annular configuration. Continuing to suspect a drug reaction, we discontinued vancomycin and performed a perilesional skin biopsy. Direct immunofluorescence demonstrated linear IgA deposition along the subepidermal basement membrane. Light microscopy revealed perivascular and interstitial inflammation. Manipulation and examination of uninvolved skin did not cause epidermal exfoliation (negative Nikolsky’s sign). In keeping with dermatology recommendations, we initiated a 5 day course of prednisone 60 mg. Following vancomycin discontinuation, no new vesicles developed and existing lesions began to heal within 2 days. The rash resolved completely within 2 weeks.
Discussion:
In this case, the patient continued therapy with the probable inciting agent for 5 days before discontinuation. As there are limited case reports of vancomycin induced LABD, the location and presentation of dermatologic findings has not been consistently described and may resemble other drug reactions such as penicillin or cephalosporin related reactions. Therefore, characteristic skin findings should serve as supporting elements for diagnosis, but the lack of such findings does not rule out vancomycin as the causative agent in a hypersensitivity reaction. Another point of interest is the timing of the reaction in relation to drug initiation. Stereotyped drug allergies, versus irritation, often occur weeks or months after beginning therapy. However in this case and other reported cases, dermatologic manifestations are evident within the first days of exposure.
Conclusions:
With increasing utilization of vancomycin as an antimicrobial therapy, we should anticipate potential, unknown side effects. Additionally, polypharmacy presents a complication when attempting to isolate a causative agent. When hypersensitivity reaction is suspected and the inciting agent is not certain, skin biopsy with immunofluorescent analysis is a reasonable approach to confirm the diagnosis. We recommend that providers develop a high index of suspicion for vancomycin induced drug reactions in order to promote timely discontinuation of the drug and confirmatory biopsy.
