Ciprofloxacin-induced Thrombotic Thrombocytopenic Purpura: A Rare Case

Abstract

Introduction: Fluoroquinolones are widely used in the clinical practice due to their broad spectrum of coverage, high oral bioavailability, and high tissue concentrations. Although usually tolerated well, a potential rare complication of fluoroquinolone-induced thrombotic thrombocytopenic purpura (TTP) has been observed. We report the rare case of a patient who developed TTP after being treated for small intestinal bacterial overgrowth (SIBO) with ciprofloxacin. Case: 77 year-old female presented to gastroenterology clinic for evaluation of chronic diarrhea which was associated with flatulence and cramping. Patient denied any history of fever, recent antibiotic use or any travel in the last few months. After her stool studies came back negative for any infectious cause, she was empirically treated with ciprofloxacin and metronidazole for 10 days for possible SIBO to which her symptoms responded well. She presented to the emergency room three days after finishing her antibiotics with symptoms of confusion and dyslexia. Her MRI of the brain and CT angiography of head and neck did not show any evidence of acute stroke. Over the next three days during her hospital stay, she developed progressive thrombocytopenia, acute renal failure, and evidence hemolytic anemia. Stool cultures were negative for Salmonella, Shigella, Campylobacter, or E. coli 0157:H7. Patient was diagnosed with thrombotic thrombocytopenic purpura likely secondary to ciprofloxacin. Plasmapheresis therapy was initiated promptly resulting in mild improvement of her renal failure, thrombocytopenia, and anemia. She was eventually started on rituximab infusions every week for 4 weeks due to inadequate response to plasmapheresis. She responded well and was able to be discharged home. She was found to be doing well at her follow-up clinic visit with normal chemistries and hematological profile. Discussion: Prompt recognition and early start of the treatment can be lifesaving in patients with TTP. Ciprofloxacin, although safe, should be kept in my mind as a possible culprit in patients who present with TTP with recent history of antibiotic use.