Introduction
Case:
A 57-year-old man with diabetes mellitus type II,
coronary artery disease, cerebral vascular
accident and alcohol use disorder presented to the emergency department (ED)
with sudden bilateral hearing loss.
Two days prior, he was evaluated in the ED for left groin and testicular pain and discharged on
levofloxacin. Patient returned to the hospital, reporting sudden hearing loss after his first dose of
levofloxacin, as well as testicular pain. He denied any recent trauma to his ears, exposure to loud
noise, otalgia, otorrhea, recent viral illness, tinnitus, or vertigo.
Review of his medication did not reveal
any recent exposure
to ototoxic medications6
Routine laboratory studies revealed leukocytosis (25.7k/cmm), chronic stable normocytic anemia (11.8g/dl) and thrombocytosis (397K/cmm). Otologic examination by otolaryngology (ENT) was unremarkable except for inability to hear tuning forks and acute reduction in hearing acuity.
Audiogram revealed bilateral sensorineural hearing loss (SNHL). MRI of the brain did not show any acute intracranial process. On hospital day one, blood cultures revealed growth of gram- positive cocci; ultimately speciated as methicillin sensitive staphylococcus aureus (MSSA).
Patient underwent three weekly trans tympanic steroid injections during his hospitalization with mild improvement in his hearing. His bacteremia was treated with an intravenous nafcillin course7.
Discussion:
Fluoroquinolones (FQ) are a popular class of
antibiotic due to their wide-ranging activity
against community gram positive and negative bacteria. The Food and Drug Administration (FDA) has issued its
strongest warning and recommended limiting use of FQ to patients who have no other treatment options due to increasing
bacterial resistance and serious safety
issues. These potentially permanent side effects can involve tendons, muscles,
joints, nerves, and central nervous
system. We report
a case of SNHL which developed suddenly
after a patient took one dose of oral fluoroquinolone. FQ are known to
be ototoxic and can result in less than
1% of patients developing tinnitus. Rarely, patients taking fluroquinolones
will develop SNHL, typically from the use of
fluroquinolone drops into the external ear canal. Based on
our literature review, SNHL from oral intake of FQs is even rarer. In cases
when cause for SNHL remains
undetermined, routine serologic tests for infection or autoimmune causes are
not recommended in the absence of
clinical suspicion for a specific etiology. Autoimmune work up including evaluation for metabolic risk
factors such as diabetes, hyperlipidemia, thyroid dysfunction could be considered. The cornerstone of therapy is steroid therapy, which can be administered via oral, intratympanic or
combined steroid. Our patient received intratympanic injections due to an active infection. Recovery from SNHL is
gradual and can take up to four to five
weeks following drug withdrawal. Early initiation of therapy, ideally withing
two weeks of onset of hearing loss,
yields a higher likelihood of response. The rate of complete recovery is unknown. In conclusion, FQ associated SNHL
is a rare but life altering, potentially permanent side effect. Counseling patients on the risk and signs of SNHL
and timely consultation of ENT to initiate therapy are critical
for best outcomes.
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