Hospital Pharmacy - May 2017 - 330

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research-article2017

HPXXXX10.1177/0018578717715349Hospital PharmacyMancano

ISMP Adverse Drug Reactions
Hospital Pharmacy
2017, Vol. 52(5) 330-333
© The Author(s) 2017
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https://doi.org/10.1177/0018578717715349
DOI: 10.1177/0018578717715349
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ISMP Adverse Drug Reactions:
Levofloxacin-Induced Neuroexcitation and Hallucinations
Statin-Induced Muscle Rupture
Mefloquine-Induced Rhabdomyolysis
Methimazole-Induced Cholestatic Hepatitis
Decitabine-Induced Hand and Foot Syndrome
Michael A. Mancano1,2

The purpose of this feature is to heighten awareness of specific adverse drug reactions (ADRs), discuss methods of
prevention, and promote reporting of ADRs to the US Food and Drug Administration's (FDA) MedWatch program (800FDA-1088). If you have reported an interesting, preventable ADR to MedWatch, please consider sharing the account with
our readers. Write to Dr. Mancano at ISMP, 200 Lakeside Drive, Suite 200, Horsham, PA 19044 (phone: 215-707-4936;
e-mail: mmancano@temple.edu). Your report will be published anonymously unless otherwise requested. This feature is
provided by the Institute for Safe Medication Practices (ISMP) in cooperation with the FDA's MedWatch program and
Temple University School of Pharmacy. ISMP is an FDA MedWatch partner.

Levofloxacin-Induced Neuroexcitation
and Hallucinations
A 2-year-old girl was admitted to the hospital after central
line placement prior to receiving a stem cell transplant. She
had a history of stage IV neuroblastoma and tolerated her
induction therapy well. She had a history of Klebsiella sepsis
and 2 episodes of neutropenic fever. She did not have any
emotional, cognitive, or behavioral disturbances; no previous psychiatric history; and no previous use of psychotropic
medication.
On day 1 of her admission, busulfan was initiated and
continued until day 5. On day 5, the patient received levofloxacin (Levaquin) prophylaxis according to an oncology
protocol for bone marrow transplantation. The patient
received levofloxacin daily until the time of engraftment.
Other medications the patient had received during this time
were acyclovir prophylaxis, fluconazole prophylaxis, ondansetron as needed, lorazepam as needed, aprepitant as needed,
cyproheptadine, cholecalciferol, omeprazole, ursodiol, oxycodone as needed, and morphine as needed.
The patient received levofloxacin at 12:12 a.m. and 8:20
p.m. on hospital day 5. Overnight, the patient's mother
reported that the patient experienced sleep disturbances with
episodes of agitation, disorientation, swatting at things that
were not there, and pinching herself. On the sixth day, the
patient did not exhibit any behavioral, cognitive, or emotional disturbances during the day. She received levofloxacin
at 9:11 a.m. and 10:38 p.m. on day 6. In the evening, she

exhibited agitation, disorientation, psychomotor agitation,
aggression, and a change in mood. She was swatting at
nurses, pulling on her garments, and crying excessively. She
developed tactile hallucinations in which she described bugs
crawling on her lower extremities. A psychiatry consult was
completed, and the patient was given a provisional diagnosis
of delirium. Psychiatry recommended that the patient's exposure to benzodiazepines be limited. The patient's mother
noted a history of similar symptoms after the patient had
received levofloxacin. Based on this information, the oncology team adjusted the dosing of levofloxacin to an earlier
time in the day.
The patient received an autologous bone marrow transplant on hospital day 7. Her second dosage of levofloxacin
was adjusted to be administered at 4:00 p.m., and melatonin
was given at 9:45 p.m. She did not experience any change in
her behavior overnight. On day 8, her second levofloxacin
dosage was administered at 6:47 p.m. and her melatonin was
given at 8:03 p.m. The patient awoke overnight with a brief
episode of visual and tactile hallucinations. This episode was
short and she exhibited less agitation and aggression overall.
1

Temple University School of Pharmacy, Philadelphia, PA, USA
Institute for Safe Medication Practices, Horsham, PA, USA

Corresponding Author:
Michael A. Mancano, Chair and Clinical Professor, Department of
Pharmacy Practice, Temple University School of Pharmacy, Philadelphia,
PA 19140, USA.
Email: michael.mancano@temple.edu

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