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KMID : 0363220170550080553
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Korean Journal of Dermatology
2017 Volume.55 No. 8 p.553 ~ p.555
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Nodular Vasculitis Associated with Cefazolin
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Kim Jae-Hwa
Lee Joong-Sun
Koo Dae-Won
Jung Kyung-Eun
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Abstract
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Nodular vasculitis (NV) is a rare condition, classified as lobular or mixed lobular and septal panniculitis with vasculitis 1,2. It usually presents in young or middle-aged female individuals1. Clinically, NV presents with recurrent crops of painful, tender, violaceous, indurated nodules mainly affecting the calves, while shins, feet, ankles, thighs, buttocks, and upper limbs may occasionally be involved1,3. Lesions tend to evolve over several weeks and often recur over many years. Ulceration and/or scarring with hyperpigmentation are frequently accompanying symptoms2.
A 65-year-old Korean woman presented with newly developed skin lesions on the extremities during a hospitalization for the control of fever, fatigue, and joint pain. She had previously been diagnosed with hypertension and chronic kidney disease, and began consecutive treatment with continuous ambulatory peritoneal dialysis (CAPD). Cefazolin (1 g) was given intravenously as antibiotic prophylaxis prior to surgical catheter insertion for CAPD. After 2 weeks, multiple reddish to violaceous nodules appeared on the upper and lower extremities, bilaterally (Fig. 1A∼D). Laboratory tests demonstrated no specific results except for a mild elevated C-reactive protein level of 1.25 mg/dL. There was no growth of bacterial, fungal, or anaerobic microorganisms in the peritoneal fluid. Drug-induced fever, Sweet`s syndrome, and serum sickness-like reactions were taken into consideration as a differential diagnosis. Histopathological examination of the skin lesions revealed septal and lobular panniculitis with inflammatory cell infiltrates and vasculitis (Fig. 2A∼C). After treatment with oral methylprednisolone 8 mg for 3 days under the diagnosis of NV, the patient`s skin lesions improved and fever disappeared.
Approximately 10 months later, the patient was given intraperitoneal cefazolin 500 mg/L dialysis fluid for 10 days because of CAPD peritonitis without skin eruption. Subsequently, tender violaceous nodules relapsed on her extremities in a few days (Fig. 1E, F). Laboratory tests showed an elevated C-reactive protein level of 2.96 mg/dL and negative HCV antibody tests. The neutrophil count was 3.34×109/L. Skin biopsy demonstrated lobular panniculitis with perivascular inflammatory infiltrates in the mid dermis to deep dermis (Fig. 2D∼F). By histological and laboratory findings, we excluded alternative diagnoses such as druginduced or infection related Sweet`s syndrome. Considering the similar previous history of being treated with the same agent cefazolin, we decided to discontinue cefazolin, and the skin lesions and symptoms markedly improved. Given the fact that the patient had been given cefazolin inadvertently and the patient`s signs and symptoms improved soon after discontinuing cefazolin and the laboratory parameters were normalized, we could assume that cefazolin was the causative agent in this case.
Cefazolin, a first generation cephalosporin antibiotic, is widely prescribed for infections to primarily cover Grampositive organisms4. The common dermatologic adverse effects of cefazolin are pruritus, urticaria, Stevens-Johnson syndrome, fixed drug eruption, erythema multiforme, and drug fever4,5. However, there has been no report of NV associated with cefazolin thus far. Herein, we report the first case of NV associated with cefazolin. The appropriate recognition of adverse cutaneous reactions to antibiotics is important for proper treatment and to adequately prevent latent fatal reactions. Our observation implies that cefazolin should be considered as a possible etiologic agent in the development of NV.
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KEYWORD
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Nodular vasculitis, Cefazolin, Cephalosporin, Vasculitis
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