Bilateral ankle pain and quinolone use: a case of tendon rupture secondary to quinolone use

Abstract

An 80-year-old man presented to the acute medical take in September 2007 with a mechanical fall at home. For the preceding 2 weeks he had developed progressive bilateral heel tenderness following a course of afloxacin prescribed by his GP for a chest infection. This spread to his calves, with the ankles giving way on weight-bearing. He had seen his GP after a week of symptoms, who had noted this as a possible rare side effect of the medication but continued the drug. He had started falling as a result of pain in the tendons, and had no history of trauma before developing these symptoms. On examination both Achilles tendons were tender with associated bruising. The ankles were hot to touch with flexion confined to 20° because of the pain. It was not possible for the patient to weight bear because of the pain. Simmonds test showed that there was no continuity of the Achilles tendon. Blood tests revealed a C-reactive protein level of 269 mg/litre. The impression was that there was bilateral Achilles tendonitis secondary to the quinolone. Simple analgesia was given and the patient was advised to immobilize because of the significant risk of rupture of the tendons. An orthopaedic opinion and magnetic resonance imaging was sought to confirm the diagnosis. This revealed bilateral rupture of Achilles tendons (Figures 1a and b), and repair was needed. A kersler suture repair and vicryl plication was performed.