Case report of Ceftriaxone induced Maculopapular Rash in a 14-year-old female

Background Ceftriaxone is commonly used for Pyrexia of unknown origin (PUO). The most frequently reported adverse effects include diarrhea, skin rash or itching, and reactions at the injection site, such as phlebitis and discomfort during intramuscular injection. Method This case was collected from the department of Pediatrics as a part of pharmacovigilance elective program of the college meant for final year MBBS students as per NMC guidelines. The collected information was further sent to the department of pharmacology being as the closest Adverse drug reaction Monitoring Centre (AMC) Conclusions Maculopapular rash is a common Adverse drug reaction (ADR) of Ceftriaxone.

The concept of pyrexia of unknown origin (PUO) originated in 1961, defining it as a prolonged fever exceeding 38.3°C (100°F) without a clear diagnosis for at least 3 weeks, including 1 week of hospital investigation. In immunocompetent individuals, infective endocarditis (particularly culture-negative endocarditis), discitis, osteomyelitis, hidden abscesses, and infected implanted devices are the leading culprits behind PUO. Supportive management is advised for (PUO) until the underlying cause is identified. The mortality rate of PUO is generally low, especially in patients well enough to undergo outpatient investigations. However, empirical treatment is warranted in three scenarios: antitubercular therapy for suspected miliary or CNS tuberculosis, antimicrobial therapy for patients with suspected infective endocarditis and signs of sepsis, and steroid treatment for potential temporal arteritis [1]. The antibiotic prescribed, ceftriaxone, is typically well tolerated by both adults and children when administered intravenously or intramuscularly. The most frequently reported adverse effects include diarrhea, skin rash or itching, and injection site reactions such as phlebitis and discomfort during intramuscular injection [2].

This case was collected from the department of Pediatrics as a part of pharmacovigilance elective program of the college meant for final year MBBS students as per NMC guidelines. The collected information was further sent to the department of pharmacology being the closest Adverse drug reaction Monitoring Centre (AMC) under Pharmacovigilance Program of India. (PvPI). The ADR was adequately followed up till resolution of the adverse drug reaction.

The case involves a 15-year-old girl who presented to the hospital with chief complaints of fever for 25 days, which was sudden in onset accompanied with chills and rigors, body pain, cough and cold. She was taken to the local hospital and given oral medication, cefdoximine, for 7 days. There was no improvement so she was given Injection cefuroxime, amikacin, piperacillin, tazobactum and clindamycin. After admission in Christian Medical College (CMC) Hospital all previous medications were stopped and the patient was started on Injection ceftriaxone 100 mg/kg body weight and syrup paracetamol 15mg/kg body weight on 29th March 2024. Following this treatment, on 2nd April 2024 patient developed erythema over cheeks, mild facial swelling, oedema over ears with erythema, multiple grouped vesicles with erythematous base noted on right dorsal aspect of hand. For this she took consultation of dermatologist who stopped Injection ceftriaxone and prescribed, Injection hydrocortisone 100 mg IV stat, Injection avil 25 mg IV, cream mometasone 0.1% for face and ears, cream clobetasol 0.05% for body lesions. Thereafter the patient started to recover from this ADR and recovered completely. Naranjo's score was 5 (probable), while the WHO-Uppsala Monitoring Centre's causality assessment also suggested a probable correlation with the current adverse event [3].

Adverse drug reactions (ADRs) are defined by the WHO as "a response to a medication that is noxious and unintended, occurring at doses normally used in humans." They're a major contributor to global morbidity and mortality [4]. Ceftriaxone is a third-generation cephalosporin, featuring an extended half-life that allows for once-daily dosing. It can be administered either intravenously or intramuscularly and exhibits a broad spectrum of activity against both gram-positive and gram-negative aerobic bacteria, as well as some anaerobic bacteria. Generally, ceftriaxone demonstrates superior activity against gram-negative bacteria compared to 'first' and 'second generation' cephalosporins, although its effectiveness against many gram-positive bacteria is somewhat lower than earlier generations of cephalosporins [2]. The most common side effects include skin and subcutaneous tissue disorders, 121,345. Out of which 14,469 are cases of maculopapular rash [5]. Drug hypersensitivity reactions occur as immune responses to medications. According to the World Allergy Organization, these reactions can be categorized based on the timing of symptom appearance as either immediate (within 1 hour of drug exposure) or delayed-type (onset after 1 hour of drug exposure). Delayed-type reactions often manifest as skin rashes or lesions. 

The incidence of ceftriaxone-related hypersensitivity reactions ranges from 1-3%. Drug rashes are typically caused by allergic reactions to a medication, presenting symptoms such as redness, bumps, blisters, hives, itching, and sometimes peeling or pain. Identifying the causative drug may require discontinuing all medications. While most drug rashes resolve upon cessation of the offending drug, mild reactions may be managed with topical creams, while severe reactions may necessitate treatment with medications like epinephrine, diphenhydramine, and/or corticosteroids to prevent complications. Drugs can induce rashes through various mechanisms [6]. In our analysis contrasting with the case report "Case Report on Ceftriaxone Induced Maculopapular Rash" by Dr. Allu Hari Krishna et al, noted that discontinuation of the suspected drug was implemented. Additionally, supplementary measures such as administering inj. dexamethasone and applying calamine lotion were prescribed to alleviate the rash [7].

Ceftriaxone is a commonly prescribed drug. If a patient experiences a skin reaction during treatment with ceftriaxone, physicians must promptly suspect and carefully evaluate the possibility of a drug-associated reaction. It is crucial to identify and document such skin reactions in the patient's medical records, and patients should be clearly instructed not to use the implicated drug to prevent recurrence in the future. Close monitoring of patients is essential, and prescriptions should be thoroughly reviewed to ensure the safest and most effective therapy with optimal economic considerations. Accurate ADR reporting promotes better communication between the treating physician and the dermatologist, and improves the patient's outcome.

Consent

Consent was taken from the patient’s guardian.

Conflict of interest

Nil