Which antibiotic can cause vasculitis?

Antibiotics That Can Cause Vasculitis

Minocycline is the antibiotic most strongly associated with drug-induced vasculitis, typically occurring after prolonged use (average 24-68 months), and requires immediate discontinuation as the primary treatment. 1, 2, 3

Primary Culprit: Minocycline

• Minocycline causes both leukocytoclastic vasculitis and polyarteritis nodosa (PAN)-like vasculitis, affecting small to medium-sized vessels 2, 3, 4
• The FDA drug label explicitly lists vasculitis as an adverse effect of minocycline, along with erythema nodosum and other cutaneous manifestations 2
• Average duration before vasculitis develops is 24-68 months of continuous therapy, though cases have been reported as early as 1 year 3, 4, 5

Clinical Presentation Patterns

Cutaneous Manifestations

• Livedoid (reticulated) erythematous lesions on extremities with subcutaneous nodules are the most characteristic presentation 3
• Nodular vasculitis (erythema induratum) affecting bilateral lower legs with painful erythematous nodules 5
• Reddish-brown reticulated erythemas with induration on lower extremities 3

Systemic Involvement (56% of cases)

• Polyarthralgia and intermittent low-grade fever accompany cutaneous lesions 3, 4
• Renal artery microaneurysms (22% of systemic cases) 4
• Mononeuritis multiplex including sciatic neuropathy 4, 6
• Mesenteric vasculitis and cholecystitis 4
• Autoimmune hepatitis with deranged liver function tests 3, 5

Diagnostic Features Distinguishing Drug-Induced Vasculitis

• Positive perinuclear ANCA (p-ANCA) pattern with negative or low-titer MPO specificity is characteristic—only 22% show true MPO positivity 1, 4
• Positive ANA with mixed antinuclear factor pattern without specific extractable nuclear antigens 4, 5
• Histopathology shows necrotizing vasculitis of small arteries at the dermosubcutaneous border or medium-vessel involvement 3, 4, 6

Other Antibiotics Associated with Vasculitis

Well-Documented Associations

• Trimethoprim-sulfamethoxazole (cotrimoxazole) is mentioned in treatment contexts but also implicated as a causative agent 7, 8
• Penicillamine has case reports of ANCA-associated vasculitis 8

Critical Distinction from Infection-Related Vasculitis

• Superficial pyogenic infections from tattoos (Staphylococcus aureus, Streptococcus pyogenes) can cause acute cutaneous vasculitis 10-14 days post-exposure with chills, arthralgia, myalgia, and purpuric rash 7
• This represents immune complex vasculitis secondary to infection, not antibiotic-induced vasculitis 7

Management Algorithm

Immediate Action

• Discontinue minocycline immediately upon clinical suspicion—this alone induces rapid resolution in most cases without immunosuppressive therapy 1, 3
• Complete resolution typically occurs within 3 months of drug cessation 3, 5

When to Add Corticosteroids

• Add prednisolone 1 mg/kg/day (maximum 60 mg/day) only if:
  • Signs of incipient skin necrosis are present 1
  • Severe systemic involvement (mononeuritis multiplex, mesenteric vasculitis) 1, 4
  • Constitutional symptoms persist after drug withdrawal 3

Critical Pitfall to Avoid

• Do NOT treat drug-induced vasculitis with cyclophosphamide or rituximab—these agents are reserved for true ANCA-associated vasculitis (AAV) and are inappropriate for drug-induced cases 1
• The presence of ANCA positivity does NOT automatically indicate need for aggressive immunosuppression in the setting of recent minocycline use 1, 4

Monitoring Recommendations

• Patients on minocycline should ideally not receive treatment exceeding 12 weeks given the cumulative risk of autoimmune complications 5
• For longer courses (acne treatment often requires extended therapy), monitor for:
  • New onset arthralgia or constitutional symptoms 3
  • Cutaneous lesions on extremities 3
  • Liver function tests every 3-6 months 5
  • Development of autoantibodies if symptoms emerge 4