Ciprofloxacin Achilles tendon rupture

Achilles tendon rupture without any sudden pain occurred in a 45-year-old female runner who developed bilateral tendinopathy of the Achilles tendon after repeated treatment with ciprofloxacin histological analysis showed cystic changes with focal necrosis (50). 

The available data suggest that the incidence of arthro-toxicity in children taking ciprofloxacin is the same as in adults the use of other fluoroquinolones is too rare to obtain clear information about the risks in children (51). In 12 children with sickle cell disease treated successfully for acute osteomyelitis with oral ciprofloxacin, transient bilateral Achilles tendon tendinitis occurred in one 5-year old (52). Another case was reported in a hemodialysis patient with a ciprofloxacin-associated Achilles tendon rupture (53). 

Achilles tendon rupture or tendinitis has occurred rarely. Renal disease, hemodialysis, and glucocorticoid use may be predisposing factors. Traditionally, the use of quinolones in children has been contraindicated because they have produced arthropathy in animal jnodels. However, children with cystic fibrosis given ciprofloxacin, norfloxacin, and nalidixic acid have had few, and reversible, joint symptoms. Therefore, the benefits may outweigh the risks in some children. 

Musculoskeletal Two cases of Achilles tendinitis [43, 44 ] and one case of Achilles tendon rupture [45 ] were reported in patients who had taken ciprofloxacin for less than a week and another case of Achilles tendon rupture 1 week after a 1-week course of ciprofloxacin [46 ]. The cases of Achilles tendon rupture occurred during exercise and were not preceded by symptoms of tendinitis. 

Akali AU, Niranjan NS. Management of bilateral Achilles tendon rupture associated with ciprofloxacin a review and case presentation. J Plast Reconstr Aesthet Surg 2008 61(7) 830-A. 

Ciprofloxacin can be associated with partial or complete tendinitis. Of 72 lung transplant recipients who received ciprofloxacin, 20 had Achilles tendon involvement (tendinitis 15, rupture 5) (49). Tendon rupture occurred at a lower dosage of ciprofloxacin than tendinitis and the mean recovery duration was significantly longer. 

Petersen W, Laprell H. Die schleichende Ruptur der Achillessehne nach Ciprofloxacin induzierter Tendopathie. Ein Fallbericht. [Insidious rupture of the Achilles tendon after ciprofloxacin-induced tendopathy. A case report.] Unfallchirurg 1998 101(9) 731-4. 

In 42 spontaneous reports of fluoroquinolone-associated tendon disorders, 32 patients had tendinitis, 24 bilaterally, and 10 had a tendon rupture most affected the Achilles tendon (89). The median age was 68 years and there was a male predominance. In 16 cases ofloxacin was implicated, in 13 ciprofloxacin, in eight norfloxacin, and in five pefloxacin. The delay between the start of treatment and the appearance of the first symptoms was 1-510 (median 6) days. Most patients recovered within 2 months after withdrawal, but 26% had not yet recovered at follow-up. 

West MB, Gow P. Ciprofloxacin, bilateral Achilles tendonitis and unilateral tendon rupture—a case report. NZ Med J 1998 111(1058) 18-19. 

In vitro, pefloxacin was more toxic to tendons than ofloxacin, ciprofloxacin, or levofloxacin (3). In rodents, pefloxacin (400 mg/kg for several days) caused oxidative damage to the type I collagen in the Achilles tendon these alterations were identical to those observed in experimental tendinous ischemia and a reperfusion model (4). Oxidative damage was prevented by the co-administration of A-acetylcysteine (150 mg/kg). Several cases of rupture of the Achilles tendon have been reported during or shortly after the use of fluoroquinolones, including five case in which pefloxacin was used (5). 

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