Case presentation
A 44-year-old male presented to our infectious disease clinic with blue-gray discoloration of the skin on August 15th, 2022. He claimed that the skin color change initiated about 20 days after levofloxacin usage as a second-line treatment for Tuberculosis. He reported pruritus and scaling on the affected skin. His past medical history included ischemic heart disease (IHD), diabetes mellitus (DM), and pulmonary tuberculosis which was diagnosed on February 22nd, 2022. Her drug history included metformin 500mg twice daily, empagliflozin 25mg/ linagliptin 5mg daily, aspirin 80mg daily, nitroglycerin 2.6 mg twice daily, rifampin 600mg/d, pyrazinamide 2gr/d, ethambutol 800mg/d, and levofloxacin 750mg/d. He was diagnosed with pulmonary tuberculosis based on positive culture from a broncho-alveolar lavage specimen. His symptoms were cough, hemoptysis, fever, weight loss, and dyspnea. Chest computed tomography (CT) scan revealed consolidation in basal segments of the lower lobe of the right lung along with bronchiectasis (Figure 1). He underwent bronchoscopy and a specimen of broncho-alveolar lavage was obtained for diagnostic evaluations including smear and culture. When TB diagnosis was confirmed by culture, he was started on first-line agents (isoniazid 300mg/d, rifampin 600mg/d, ethambutol 800mg/d, and pyrazinamide 2gr/d). After two months of the intensive phase, the continuation phase was started with isoniazid and rifampin until the infection was recognized as isoniazid-resistant TB according to the drug susceptibility testing (DST) findings. Therefore, isoniazid was replaced with levofloxacin. After 20 days he developed blue-gray discoloration of the skin and came back to our infectious disease clinic.
On physical examination, vital signs were stable. Blue-gray discoloration of the skin with fine scaling was observed on the face, forearms, legs, and abdomen. We also detected, alopecia areata with ophiasis pattern (Figures 2 &3). Examination of the respiratory and cardiovascular systems was within normal limits.
Since levofloxacin was the only drug started a short time before the initiation of skin discoloration, it was considered the culprit drug. Therefore, all medications, including levofloxacin, were discontinued. The sputum sample was sent to check the resistance to rifampin by the Gene Expert method. In this experiment, Mycobacterium tuberculosis sensitive to rifampin was reported. During hospitalization, following the discontinuation of drugs (including levofloxacin), edema of the limbs and scaling were resolved, and the hyperpigmentation became lighter. With the possibility of a drug complication to levofloxacin and due to drug resistance to isoniazid, a 4-drug treatment regimen was started with isoniazid, rifampin, pyrazinamide, and ethambutol, and the patient was discharged from the hospital after tolerating the drug regimen.
The patient was followed up 6 weeks after the discontinuation of levofloxacin. The blue-gray pigmentation was observed with a much lower intensity, and an almost complete resolution was observed after 6 months (Figure 4).