Disclosures: Alyssa M. Volmrich, MD, MBA: No financial relationships or conflicts of interest

Case Diagnosis: Bilateral Fluoroquinolone Associated Shoulder Tendinopathy

Case Description or Program Description: A 65-year-old female, with no prior musculoskeletal issues, presents with acute atraumatic bilateral arm pain radiating from shoulders to the mid-arm anterolaterally. Pain is constant and exacerbated with activities, such as getting dressed. Prior to this, she was bitten by her dog and developed a right index finger infection. Initial treatment with amoxicillin-clavulanic acid and trimethoprim-sulfamethoxazole was stopped due to pruritis and rash. Then, she was diagnosed with septic arthritis and osteomyelitis by Hand Surgery and underwent right index finger distal interphalangeal joint irrigation and debridement. Infectious Disease placed her on a 10-day course of metronidazole, doxycycline, and levofloxacin. Approximately 10 days into her treatment course, she reported muscle aches. She developed persistent pain despite cessation of metronidazole, doxycycline and subsequently levofloxacin.

Setting: University Affiliated Outpatient Clinic

Assessment/Results: Shoulder diagnostic musculoskeletal ultrasound revealed tendinosis of long head of the biceps with tenosynovitis and partial-thickness interstitial tendon tear, partial-thickness infraspinatus, subscapularis tendon, and supraspinatus (1.1 x 0.9 cm) tendon tears on the right. On the left, tendinosis and tenosynovitis of long head of the biceps, focal full thickness supraspinatus tendon (1 x 1.6 cm), and partial-thickness tears of infraspinatus and subscapularis tendons

Discussion (relevance): The association between fluoroquinolones and tendon pathology is rare but well-documented. Symptoms appear 1-2 weeks after initiating fluoroquinolones, typically involve the Achilles, and generally affect males over 60. The pathophysiology is related to direct toxicity and tendon ischemia. To our knowledge, there have only been three documented cases of rotator cuff tendinopathy. Additionally, those documented cases were all unilateral in nature compared to this patient with bilateral pathology.

Conclusions: This appears to be the only documented case of bilateral, symmetric rotator cuff tendinopathy after fluoroquinolone use. It is important to consider this potential complication even in patients with no known risk factors.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/taking-a-bite-out-of-antibiotic-associated-tendinopathy-a-case-report/