Drug-Induced Leukocytoclastic Vasculitis From an Unreported Source: Daptomycin

Abstract

Leukocytoclastic vasculitis (LCV) is a rare small-vessel vasculitis caused by immune-complex-mediated deposition on endothelial cells of dermal capillaries. Common triggers include medications, infections, autoimmune disorders, and malignancies. We present a case of a 58-year-old male who developed daptomycin-induced LCV after being treated for Methicillin-resistant Staphylococcus aureus (MRSA) endocarditis. The patient experienced painful palpable purpura on his lower extremities, which was diagnosed as LCV by skin biopsy. At the time of the biopsy, warfarin and daptomycin were discontinued, and the patient was transitioned to heparin and ceftaroline. MRSA-induced LCV was ruled out, due to negative blood cultures and adequate source control of his infection at the time of development of the skin lesions. Warfarin-induced skin necrosis (WISN) was ruled out based on histopathological findings. This case is clinically significant as it represents the first reported case of LCV associated with daptomycin use. It underscores the importance of considering the patient's history, clinical presentation, and histopathological findings to ensure prompt recognition and management of this rare drug reaction, allowing for the resolution of LCV.

Keywords: antibiotic adverse effects; cutaneous drug reaction; daptomycin adverse reaction; drug-induced vasculitis; histopathology of vasculitis; immune complex-mediated vasculitis; leukocytoclastic vasculitis (lcv); mrsa endocarditis; small vessel vasculitis.

Figure 1. Right lower extremity painful, necrotic appearing purpura with surrounding erythema.

Figure 2. Erythematous macule with palpable purpura on the right lower extremity.

Figure 3. Biopsy of the right lower extremity demonstrating LCV.

The black circles demonstrate vessels with inflammation marked by fibrin deposition and neutrophil invasion. The green bracket highlights the area of neutrophils (polymorphonuclear cells) and fragmentations of neutrophils (leukocytoclasia). Blue arrows mark eosinophilic regions representing fibrin deposition on vessels.

Figure 4. Patient’s right lower extremity at the one-month follow-up visit after discontinuation of daptomycin revealing resolution of purpuric lesions, with post-inflammatory changes of dyspigmentation and crusted re-epithelializing tissue being present.

Figure 5. Timeline of the patient's clinical events.