What are the risks of starting a 20 mg short course of steroid (corticosteroid) for 5 days in a 50 kg male with burning feet and itching after taking levofloxacin (levofloxacin) and having thrombocytopenia (platelet count of 75,000) with a history of urinary tract infection (UTI) with prior pus cells?

Risks of Short-Course Corticosteroids in a Patient with Thrombocytopenia and Burning Feet After Levofloxacin

Starting a 5-day course of 20 mg corticosteroids in this patient with thrombocytopenia (75,000 platelets) and burning feet after levofloxacin is relatively safe and may help alleviate symptoms, but should be monitored closely for potential worsening of the underlying condition.

Understanding the Clinical Scenario

This case presents multiple interconnected issues:

1. Thrombocytopenia (75,000 platelets)
2. Burning feet and itching symptoms
3. Recent levofloxacin exposure
4. History of UTI with pus cells
5. No current fever

Fluoroquinolone-Induced Thrombocytopenia

Levofloxacin is a known but rare cause of drug-induced immune thrombocytopenia (DIT) 1. The mechanism involves drug-dependent antibodies targeting platelet surface glycoproteins, leading to increased platelet destruction 2. Similar cases have been reported with other fluoroquinolones such as ciprofloxacin 3 and moxifloxacin 4, 5.

Burning Feet and Itching

These symptoms likely represent peripheral neuropathy, a known adverse effect of fluoroquinolones, potentially exacerbated by the immune reaction causing thrombocytopenia.

Risk Assessment for Corticosteroid Use

Benefits of Corticosteroid Treatment

• May help reduce immune-mediated platelet destruction
• Can alleviate neurological symptoms and itching
• Short course (5 days) minimizes long-term steroid complications

Risks of Corticosteroid Treatment

1. Masking Infection: Corticosteroids may mask signs of infection in a patient with recent UTI 6
2. Blood Glucose Effects: Can cause hyperglycemia, especially in elderly patients 6
3. Mood/Sleep Disturbances: Even short courses can cause sleep and mood alterations 6
4. Potential Impact on Platelet Recovery: While corticosteroids are used to treat ITP, the mechanism of fluoroquinolone-induced thrombocytopenia differs, and steroid response may be unpredictable

Recommended Approach

Monitoring Requirements

If proceeding with corticosteroid treatment:

• Monitor platelet counts daily during treatment
• Check blood glucose levels regularly
• Assess for signs of infection (despite absence of fever)
• Monitor blood pressure
• Evaluate for sleep disturbances and mood changes

Alternative Considerations

For severe or worsening thrombocytopenia (if platelets drop below 30,000 or bleeding occurs):

• IVIG (0.8-1 g/kg) provides more rapid increase in platelet counts than corticosteroids 6
• Discontinuation of any other potentially causative medications

Special Considerations

1. Dosing: The proposed 20 mg dose (approximately 0.4 mg/kg for a 50 kg patient) is within the recommended range for ITP (0.5-2 mg/kg/day) 6

2. Duration: The 5-day course is appropriate and aligns with recommendations to limit corticosteroid exposure 6

3. Discontinuation of Levofloxacin: Ensure levofloxacin has been discontinued, as case reports show platelet recovery typically begins after drug discontinuation 1

Conclusion

The short course (5 days) of corticosteroids at 20 mg daily presents a reasonable benefit-to-risk ratio for this patient. The primary risks include potential masking of infection and metabolic effects, but these are minimized by the short duration. Close monitoring of platelet counts is essential, with readiness to pivot to IVIG if thrombocytopenia worsens or bleeding occurs.