A Case of Linezolid Toxicity Presenting as a Sepsis Mimic.

Rashmi Mishra,Bindu Goel,Trupti Vakde,Harish Patel

doi:10.1155/2019/2157674

Abstract

Linezolid is an efficacious and well tolerated antimicrobial but can have serious adverse effects including myelo-suppression, serotonin syndrome, neuropathy, hypoglycemia, liver dysfunction, and lactic acidosis. The side effects are generally duration dependent; linezolid use is not recommended for more than 28 days. Case. A 59-year-old female presented with malaise, loss of appetite, and altered mentation. She had multiple medical comorbidities and required long-term anticoagulation with warfarin for venous thromboembolism. She had multiple medication allergies. Prior to admission, she was on linezolid for cellulitis of foot due to Methicillin-resistant Staphylococcus aureus (MRSA). On physical exam, she was drowsy and required endotracheal intubation for airway protection. Initial laboratory parameters showed lactic acidosis, thrombocytopenia, supra-therapeutic coagulation profile, low blood glucose, and transaminitis. Her altered mentation was due to hypoglycemia. The interaction with warfarin led to altered coagulation profile. She developed shock and vasopressors were initiated. Given her presentation, she was managed as severe sepsis. There were no active infectious foci attributing to decline of her clinical status. Linezolid was discontinued and she was managed with intravenous polymyxin B, aztreonam, and vancomycin. Her hemodynamic status improved within one day. She was extubated on Day 5 of her presentation. Her laboratory parameters showed gradual improvement over 12 days after discontinuation of linezolid. Retrospective evaluation revealed linezolid toxicity as possible cause of presentation. Linezolid toxicity can present as sepsis mimic and should be considered as a differential diagnosis while managing sepsis with other antimicrobial agents.

Highlights

Linezolid is an oxazolidinedione antibiotic approved for use against serious Gram-positive infections, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus faecium [1]
Antibiotics are used for the management of the bacterial infection. e antimicrobial induced adverse events, like lactic acidosis, can be confused with presentation of severe sepsis
We present a novel case of the linezolid toxicity presenting with a rare constellation of adverse events in the form of thrombocytopenia, lactic acidosis, hypoglycemia, and warfarin toxicity

Summary

Introduction

Linezolid is an oxazolidinedione antibiotic approved for use against serious Gram-positive infections, including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus faecium [1]. Few weeks prior to her index presentation, she was hospitalized for foot infection Infectious disease consultation was obtained and in view of the allergy to moxifloxacin and renal insufficiency, 3 weeks of the linezolid was recommended. Ere was interval improvement in cellulitis and foot ulcer She presented to our ER few days a er the clinic assessment. Infectious disease follow-up recommended vancomycin levels to guide subsequent dose and bacterial cultures for titration of antibiotics Her blood culture and wound culture from infection site were negative for any bacterial growth. Given the absence of septic foci, the clinical scenario supported the presentation to be a constellation of adverse events from linezolid and she did not require the additional antibiotics therapy

Discussion

Conclusion