Fluconazole
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Various toxicities secondary to misuse: case report A 54-year-old man developed polyneuropathy (PNP), GI bleeding, acute renal failure and thrombotic thrombocytopenic purpura (TTP) secondary to misuse of fluconazole for onychomycosis. The man, whose medical history was notable for hypertension, was hospitalised due to numbness and weakness in both feet, which had gradually worsened over time, causing difficulty in ambulation. Neurological examination revealed generalised areflexia and bilateral weakness in ankle dorsiflexion (4/5). During the course of diagnostic evaluation for pre-diagnosis PNP, acute and diffuse defecation of tarry stools (GI bleeding) led to admission. Over the subsequent days, his gait became abnormal. The results of laboratory analyses were normal apart from a reversed albumin/globulin ratio, high IgA levels, low serum IgG and IgM, and slightly elevated creatinine and blood urea nitrogen (BUN). Bone marrow biopsy showed normal elements. During inpatient follow-up, repeated neurological investigations demonstrated severe hypoesthesia in glove-stocking distribution and areflexic quadriparesis (3/5). Electromyogram-electroneurogram (EMG-ENG) revealed severe diffuse sensorimotor PNP with axonal demyelination and degeneration. Meanwhile, creatinine and BUN levels rapidly increased, leading to the diagnosis of acute renal failure. The man underwent haemodialysis for the acute renal failure. After three dialysis sessions, his renal function returned to baseline; however, his WBC counts-particularly platelets-rapidly declined, leading to the diagnosis of TTP, for which he required apheresis. He became completely immobile within a few days. Repeat EMG-ENG revealed similar findings, whereas his blood counts improved after five sessions of apheresis. Following a detailed review of his past medical history, he admitted ingesting fluconazole 200 mg/day for 1 month for onychomycosis without a prescription (misuse). He discontinued the medication when he was first admitted for his neurological symptoms. Therefore, the PNP, GI bleeding, acute renal failure and TTP were presumed to be adverse drug reactions to fluconazole [times to reactions onsets not clearly stated]. His clinical condition gradually improved, and he was able to walk with the help of a walker by the end of month 4 of admission. Repeat EMG-ENG revealed persistence of areflexia and glovestocking hypoesthesia. By month 8, he expressed his well-being and self mobility by telephone contact. By the end of the first year, he was able to perform all his daily activities by himself. Eskut N, et al. Acute fluconazole toxicity: a case presenting with protean manifestations including systemic and neurologic symptoms. Postgraduate Medicine : 12 Nov 2020. 803521193 Available from: URL: http://doi.org/10.1080/00325481.2020.1840830
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Reactions 12 Dec 2020 No. 1834
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