Publication:

Proteinase 3-antineutrophil cytoplasmic antibody positive necrotizing vasculitis induced by ciprofloxacin

Granulomatosis with polyangiitis (Wegener’s), microscopic polyangitis, and eosinophilic granulomatosis with polyangiitis are commonly grouped together as antineutrophil cytoplasmic antibody (ANCA)-positive vasculitides. Many drugs and infections can induce serologic positivity for ANCA, while a few can precipitate overt ANCA-positive vasculitis. Although fluoroquinolones have been reported to cause ANCA-negative leukocytoclastic vasculitis (LCV), fluoroquinolones are not known to induce proteinase 3-ANCA (PR3-ANCA)-positive vasculitis. Here, we present the case of a middle-aged man who developed severe headache, purpura on legs and numbness in hands and feet after taking ofloxacin for 5 days. Subsequently, he was diagnosed with ANCA-negative LCV and treated with steroids and immunosuppressants. Thirteen years later, he inadvertently received intravenous ciprofloxacin and developed severe headache and epistaxis. Serologic testing at that time revealed elevated titers of PR3-ANCA. Biopsy of nasal septum revealed a mixed mononuclear and polymorphonuclear infiltrate without evidence of granuloma formation. He was treated with steroids and immunosuppressive therapy. Over the next several years, he remained stable with residual hearing loss and nasal septal deformity. This case provides the first evidence for a PR3-ANCA-positive necrotizing vasculitis induced by ciprofloxacin.