A Case of Levofloxacin-Induced Anaphylaxis With Elevated Serum Tryptase Levels
A 58-year-old male was admitted with dyspnea. Fifteen days prior to admission, the patient had been hospitalized due to asthma exacerbations. The patient developed fever on the third day of hospitalization and was given 250 mg of levofloxacin orally. Two and a half hours later, the patient developed sudden dizziness and a skin rash, and his asthma worsened. He was treated without antibiotics and discharged with improved symptoms. However, 5 days after admittance to our hospital, his dyspnea worsened.\nThere were erythematous papules over the patient's entire body, and blisters were observed around his lips. The patient had visited a dermatology clinic 2 days prior. A biopsy had been performed on the patient's blisters and he was diagnosed with a herpes infection. Peripheral blood tests revealed a white blood cell count of 7,070/µL (6.0% eosinophils), a hemoglobin level of 15.5 g/dL, and a platelet count of 313,000/µL. Biochemistry tests returned the following results: AST, 146 U/L; ALT, 698 U/L; ALP, 233 U/L; gamma-GT, 868 U/L; total bilirubin, 3.1 mg/dL; and direct bilirubin level, 1.9 mg/dL. The patient's total serum immunoglobulin E (IgE) level was 150 U/mL. A chest X-ray and liver computed tomography (CT) did not reveal any abnormalities. All viral markers for hepatitis were negative. In addition, skin prick tests for 55 allergens were negative. A pulmonary function test (PFT) showed an FEV1/FVC of 59.1%, an FEV1 of 2.14 L (70%), and an FVC of 3.62 L (86%). The PC20 in a methacholine bronchial provocation test was 6.46 mg/mL.\nAfter the patient's dyspnea subsided, he was given 250 mg of levofloxacin at 10:00 AM and spirometry was performed every 30 minutes thereafter. The patient's peak expiratory flow rate (PEFR) was evaluated every hour beginning at 3 hours after oral provocation (). At 3.5 hours following oral provocation, a skin rash developed over the patient's entire body () and he complained of dyspnea. At this time, the patient's FEV1 had decreased by 22% to 1.15 L. The patient inhaled salbutamol, and after 15 minutes his FEV1 was 1.62 L (53%). The patient complained of dizziness at 4 hours and 10 minutes after provocation; at this time, his blood pressure dropped to 67/45 mmHg. The patient was stabilized with shock positioning and a rapid saline drip. He was then given 10 mg of chlorpheniramine and 125 mg of methylprednisolone intravenously. We prepared the epinephrine before the provocation test, but mistakenly did not administer it. Two hours after the patient's blood pressure began to drop, his serum tryptase level was 17.7 µg/L (1.9-13.5 µg/L). There were no changes in PEFR during the first 13 hours and following 2 days.