The Dark Purple Side of Ceftriaxone: A Case Report on Leucoc
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In this case, the most interesting aspect was the diagnostic challenge before the skin biopsy result. A systemic vasculitis was excluded; immunological blood tests did not yield any significant results.

Doctors considered a drug reaction: digoxin and ceftriaxone were started after hospital admission concomitant with skin lesion appearance, but the clinical features were more suggestive of phenprocoumon involvement.

The first clinical suspicion was “late-onset warfarin-induced skin necrosis”, a rare complication of therapy with warfarin and coumarin derivatives.

A case of an 85-year-old woman diagnosed with uncomplicated pyelonephritis, who was treated with intravenous ceftriaxone. Her chronic medications were phenprocoumon, diltiazem and bisoprolol. During the infectious phase, the patient presented tachycardia- despite high-dose beta-blocker treatment- and developed left acute heart failure, with acute renal failure (pre-renal origin).

After introduction of furosemide diuretic therapy, clinical conditions improved and better control of the volemic status and heart rate was achieved. Several days after ceftriaxone and digoxin therapy initiation, worsening multiple non-blanching palpable purpuric lesions with bullae and papules, limited to the lower extremities, were noted. Skin biopsy was performed and a diagnosis of leucocytoclastic vasculitis, with associated panniculitis, was made. Ceftriaxone was discontinued and systemic corticosteroids were introduced, with a clear improvement in the cutaneous condition.

Doctors finally considered the hypothesis of a reaction due to recently introduced drugs: digoxin has not been shown to produce similar reactions, whereas ceftriaxone-induced leucocytoclastic vasculitis has been described.

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