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 Table of Contents  
Year : 2019  |  Volume : 24  |  Issue : 2  |  Page : 101-102

A rare case report of levofloxacin- and solifenacin-induced acute anaphylactic reaction in an elderly patient

1 Department of Pharmacology, Government Medical College, Aurangabad, Maharashtra, India
2 Department of Pharmacology, SMBT IMS and RC, Nashik, Maharashtra, India

Date of Web Publication17-Sep-2019

Correspondence Address:
Dr. Satish Eknath Bahekar
Department of Pharmacology, Government Medical College, Aurangabad, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmgims.jmgims_16_17

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Drug-induced acute anaphylactic reactions are rare in general. Antibiotics and anticholinergic agents are widely used for renal conditions such as hematuria and overactive bladder, respectively. However, anaphylactic reactions to this category of drugs are very rare, but many times fatal. These types of serious reactions are very important to watch for. Here, we are reporting levofloxacin and solifenacin-induced acute anaphylactic reaction in a 66-year-old male patient.

Keywords: Acute anaphylactic reaction, levofloxacin, overactive bladder, solifenacin

How to cite this article:
Bahekar SE, More PD. A rare case report of levofloxacin- and solifenacin-induced acute anaphylactic reaction in an elderly patient. J Mahatma Gandhi Inst Med Sci 2019;24:101-2

How to cite this URL:
Bahekar SE, More PD. A rare case report of levofloxacin- and solifenacin-induced acute anaphylactic reaction in an elderly patient. J Mahatma Gandhi Inst Med Sci [serial online] 2019 [cited 2020 Oct 19];24:101-2. Available from: https://www.jmgims.co.in/text.asp?2019/24/2/101/267002

  Introduction Top

Elderly age group is frequently associated with various health-related issues. Renal complaints comprise one of the important groups among them. Among these, overactive bladder (OAB) and hematuria are most commonly encountered health problems in this age group. It affects an estimated 10%–31% of the global population.[1] It results in significant quality of life impairment due to urinary urgency, frequency, and nocturia.[2] Anticholinergic medications have been the mainstay in pharmacologic management of OAB.[3] Currently, various urological associations have recommended anticholinergic agents such as oxybutynin, tolterodine, fesoterodine, solifenacin, darifenacin, and trospium.[4] Fluoroquinolones (FQs) are one of the most widely used antimicrobials for empirical therapy of urinary tract infections including hematuria. Among these, levofloxacin is the active levo(s) isomer of ofloxacin having improved activities against various bacteria. Common adverse effects include nausea, vomiting, diarrhea, headache, and constipation. Others are dizziness, difficulty in sleeping, rash, abdominal pain, tendinitis, rupture of tendons, and photosensitivity.[5] However, levofloxacin-induced anaphylaxis is rare, although there have been a few reported cases.[6] However, no case of solifenacin-induced acute anaphylaxis has been reported in the past. Here, we are reporting a case of levofloxacin and solifenacin-induced acute anaphylactic reaction in an elder patient.

  Case Report Top

A 66-year-old male patient visited the surgery outpatient department with complaints of burning micturition, urinary urgency, frequency, and hematuria for 1 week. There were no other associated complaints such as pain in abdomen, fever, vomiting, and bowel complaints. He was neither diabetic nor hypertensive. He was admitted to the surgery ward. Routine investigations were carried out such as complete blood count, urine routine and microscopy and ultrasonography (USG) abdomen. Hematological investigations were within normal limits, however, there was the presence of insignificant red blood cells and pus cells in urine; USG abdomen also revealed normal findings with no signs of prostate hypertrophy. Diagnosis of OAB with hematuria was made. The patient was started with oral levofloxacin (500 mg) once a day and solifenacin (5 mg) twice a day. Both medications were consumed at once. After 10 min, he started flushing in the face and neck, confusion, tachycardia with pulse rate 120 beats/min, hypotension (blood pressure: 80/30 mmHg), and severe itching with rash over both soles and palms which immediately spread all over the body. It was associated edema over both hands and legs and soon spread all over the body. This was accompanied by shortness of breath which converted into bronchospasm. He was immediately admitted to the Intensive Care Unit and administered adrenaline (0.5 mg) intramuscularly, pheniramine maleate (2 ml) intravenously, and injection hydrocortisone (100 mg) intravenously. This was accompanied with all necessary general measures such as airway support and additional intravenous line with saline. The patient's symptoms declined and his clinical condition improved in the following hours and edema started to subside. Both levofloxacin and solifenacin were immediately stopped.

  Discussion Top

Geriatric population is the most vulnerable population susceptible for various health-related disorders as well as drug-induced adverse effects. OAB is one of the most frequently encountered issues in this regard as it is associated with impairment of quality of life. Anticholinergic medications despite being the mainstay of its management, there is an issue of high discontinuation rates thought to be due to both the lack of efficacy and the side effects of anticholinergic medications.[7] Among these, solifenacin is selective muscarinic (M3) receptor antagonist in the bladder which belongs to the category of newer anticholinergic with relatively low adverse drug reactions profile, has became more popular for the treatment of OAB.[8] However, its use is associated with the anticholinergic side effects such as dry mouth, constipation, somnolence, blurred vision, and cognitive impairment, suggesting the importance of bladder selectivity. However, not even a single case of solifenacin-induced acute anaphylactic reaction has been mentioned in the literature.

Levofloxacin is a commonly used antibiotic for the treatment of variety of renal infections. However, various adverse effects have been observed with its use including hypersensitivity. There are reports of serious and occasionally fatal hypersensitivity and/or anaphylactic reactions in patients receiving therapy with first dose of levofloxacin. These reactions are often accompanied by cardiovascular collapse, hypotension/shock, seizure, loss of consciousness, tingling, angioedema, bronchospasm, shortness of breath and acute respiratory distress, urticaria, itching, and other serious skin reactions.[9] It has been reported that 0.46–1.2 out of 100,000 individuals treated with fluoroquinolones develop anaphylaxis.[10] Although an exact mechanism has not been elucidated, studies suggest that the release of mediators such as histamine, which results from the high penetrability of fluoroquinolone into cells, plays an important role in the development of anaphylaxis.[11]

On the basis of the guidelines given in Naranjo Adverse Drug Reaction Probability Scale and WHO-UMC causality categories, this ADR comes in probable category.[12]

In this case, as both levofloxacin and solifenacin are given concurrently, the occurrence of acute anaphylactic reaction cannot be attributed to either agent. Keeping in mind the severity of the reaction, rechallenge with the same drugs was not possible and ethical too. However, as per the evidence from literature, levofloxacin can be held responsible for the reaction; still, the role of solifenacin cannot be completely ruled out.

  Conclusion Top

Solifenacin and levofloxacin being commonly used drugs for the management of renal complaints, these types of fatal reactions should always be keep in mind.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Irwin DE, Milsom I, Hunskaar S, Reilly K, Kopp Z, Herschorn S, et al. Population-based survey of urinary incontinence, overactive bladder, and other lower urinary tract symptoms in five countries: Results of the EPIC study. Eur Urol 2006;50:1306-14.  Back to cited text no. 1
Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010;29:4-20.  Back to cited text no. 2
Gormley EA, Lightner DJ, Burgio KL, Chai TC, Clemens JQ, Culkin DJ, et al. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. J Urol 2012;188:2455-63.  Back to cited text no. 3
Bettez M, Tu le M, Carlson K, Corcos J, Gajewski J, Jolivet M, et al. 2012 update: Guidelines for adult urinary incontinence collaborative consensus document for the Canadian Urological Association. Can Urol Assoc J 2012;6:354-63.  Back to cited text no. 4
Tripathi KD. Sulfonamides, cotrimoxazole and quinolones. In: Essentials of Medical Pharmacology. 7th ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2013. p. 708-13.  Back to cited text no. 5
Takahama H, Tsutsumi Y, Kubota Y. Anaphylaxis due to levofloxacin. Int J Dermatol 2005;44:789-90.  Back to cited text no. 6
Benner JS, Nichol MB, Rovner ES, Jumadilova Z, Alvir J, Hussein M, et al. Patient-reported reasons for discontinuing overactive bladder medication. BJU Int 2010;105:1276-82.  Back to cited text no. 7
Kalder M, Pantazis K, Dinas K, Albert US, Heilmaier C, Kostev K, et al. Discontinuation of treatment using anticholinergic medications in patients with urinary incontinence. Obstet Gynecol 2014;124:794-800.  Back to cited text no. 8
Ghoshal A, Damani A, Salins N, Deodhar J, Muckaden MA. Management of levofloxacin induced anaphylaxis and acute delirium in a palliative care setting. Indian J Palliat Care 2015;21:76-8.  Back to cited text no. 9
[PUBMED]  [Full text]  
Smythe MA, Cappelletty DM. Anaphylactoid reaction to levofloxacin. Pharmacotherapy 2000;20:1520-3.  Back to cited text no. 10
Kelesidis T, Fleisher J, Tsiodras S. Anaphylactoid reaction considered ciprofloxacin related: A case report and literature review. Clin Ther 2010;32:515-26.  Back to cited text no. 11
Zaki SA. Adverse drug reaction and causality assessment scales. Lung India 2011;28:152-3.  Back to cited text no. 12
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