Case report
Kidney transplantation
Fluoroquinolones-Induced Tendinitis and Tendon Rupture in Kidney Transplant Recipients: 2 Cases and a Review of the Literature

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Abstract

Fluoroquinolones are an important class of synthetic antibiotics and their use recently expanded with a new activity against Gram positive and anaerobics. In the literature many side effects were documented and, among them, tendinitis and subsequent tendon rupture are important causes of morbidity. The incidence is 0.14% to 0.4% but, in the kidney recipient population, the phenomenon is even more common (incidence, 12.2%–15.6%). Advanced age seems to be the most significant risk factor. Long period of hemodialysis, diabetes mellitus, hyperparathyroidism, rheumatic diseases, gout, and corticosteroids are the other predisposing factors in kidney recipients, even if they are still under discussion. All of these risk factors can create a synergistic toxicity or at least an additive effect. A case of tendinitis and a case of bilateral Achilles tendon ruptures in 2 kidney recipients are described and a brief discussion of the literature is presented.

Section snippets

Case 1

A 54-year-old woman suffered renal failure for 4 years, received vascular dialysis for 2 years, and was finally submitted to undergo double kidney transplantation 1 year ago (from a marginal donor). She received immunosuppressive therapy with prednisolone (4 mg/d), cyclosporine (150 mg/d), and mycophenolate (1000 mg/d). Six months after transplantation, she started a 10-day antibiotic course with ciprofloxacin (500 mg twice daily) for a urinary tract infection. Two weeks later, 5 days after the

Case 2

A 60-year-old woman suffered renal failure with hyperparathyroidism for a Berger disease since 1998. She underwent vascular dialysis in 2000 and transplantation in 2002. Immunosuppressive therapy was based on prednisolone (8 mg/d), azathioprine (50 mg/d), and Fk (2.5–3 mg/d). She received ciprofloxacin for 7 days to treat a urinary tract infection. During the antibiotic course, she experienced pain in the left Achilles tendon with local edema and difficulty in standing up or during ambulation.

Discussion

Tendon disorders associated with fluoroquinolones have been estimated to occur at a rate of approximately 15–20 per 100,000 patients.12 Tendinitis involves most commonly Achilles tendons, but also quadriceps, peroneus brevis, extensor pollicis longus, long head of biceps, and rotator cuff tendons.12 Possible risk factors have been investigated. Long-term steroid therapy, renal insufficiency, advanced age, prior tendinopathies, magnesium deficiency, hyperparathyroidism, diuretic use, peripheral

Conclusions

Awareness of the association between tendon disorders and fluoroquinolones should lead to a careful assessment of patients. The evaluation of specific risk factors and an enhanced surveillance for suspicious symptoms, especially in transplant recipients, should be mandatory. Patients should be correctly advised of the possibility of tendon disorders, during or after fluoroquinolone treatment, and counselled to immediately suspend treatment and to rest when symptoms occur. Furthermore, even if

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