Ciprofloxacin-Induced Extensor Tendon Rupture in the Hand: A Case Report

Uremic Toxins and Ciprofloxacin Affect Human Tenocytes In Vitro

Tendinopathy is a rare but serious complication of quinolone therapy. Risk factors associated with quinolone-induced tendon disorders include chronic kidney disease accompanied by the accumulation of uremic toxins. Hence, the present study explored the effects of the representative uremic toxins phenylacetic acid (PAA) and quinolinic acid (QA), both alone and in combination with ciprofloxacin (CPX), on human tenocytes in vitro. Tenocytes incubated with uremic toxins +/- CPX were investigated for metabolic activity, vitality, expression of the dominant extracellular tendon matrix (ECM) protein type I collagen, cell-matrix receptor β1-integrin, proinflammatory interleukin (IL)-1β, and the ECM-degrading enzyme matrix metalloproteinase (MMP)-1. CPX, when administered at high concentrations (100 mM), suppressed tenocyte metabolism after 8 h exposure and at therapeutic concentrations after 72 h exposure. PAA reduced tenocyte metabolism only after 72 h exposure to very high doses and when combined with CPX. QA, when administered alone, led to scarcely any cytotoxic effect. Combinations of CPX with PAA or QA did not cause greater cytotoxicity than incubation with CPX alone. Gene expression of the pro-inflammatory cytokine IL-1β was reduced by CPX but up-regulated by PAA and QA. Protein levels of type I collagen decreased in response to high CPX doses, whereas PAA and QA did not affect its synthesis significantly. MMP-1 mRNA levels were increased by CPX. This effect became more pronounced in the form of a synergism following exposure to a combination of CPX and PAA. CPX was more tenotoxic than the uremic toxins PAA and QA, which showed only distinct suppressive effects.

Fluoroquinolone-Associated Tendinopathy of the Hand and Wrist: A Systematic Review and Case Report

BACKGROUND

Fluoroquinolone use has been known to be associated with tendinopathy and tendon rupture for over 30 years. Hand and wrist involvement has been reported rarely, yet without early recognition and withdrawal of the fluoroquinolone, there is potential for significant morbidity.

METHODS

We searched Medline using a comprehensive search strategy for fluoroquinolones and tendinopathy of the hand and wrist, and provide a case report of a possible levofloxacin-related tendon rupture in a patient with a previous mutilating hand injury.

RESULTS

We located 10 previously reported cases of fluoroquinolone-associated tendinopathy in the hand or wrist ranging from 1983 to 2015. Unlike Achilles tendinopathy, women were no more likely than men to have tendon rupture affecting the hands or wrists. Our patient was a 59-year-old man with prior tendon repair but otherwise noncontributory medical history who experienced spontaneous tendon rupture on an extended course of levofloxacin and required extensive pulley and boutonnière repair.

CONCLUSIONS

Given the extensive damage that may be caused to weakened tissue, clinicians should maintain a high index of suspicion of tendinopathy in patients taking fluoroquinolones who have had previous tendon repairs, particularly in the setting of unexplained changes in recovery trajectory.