Ciprofloxacin-induced Stevens-Johnson Syndrome with Grapefruit Juice Consumption: A Case Report

We describe the case of a 49-year-old, otherwise healthy, Hispanic male who underwent an uncomplicated vasectomy and was treated prophylactically with a one-week course of ciprofloxacin. Two days after completing the antibiotic course, he developed a pruritic, blistering rash that covered 90% of his body surface area. Punch biopsy of the skin lesions confirmed the diagnosis of Stevens-Johnson syndrome (SJS). Upon further questioning, it was revealed that the patient had consumed approximately 32 ounces of grapefruit juice each of the seven days following his vasectomy. We hypothesized that the cytochrome P450 inhibitory effect of grapefruit juice had dramatically elevated systemic levels of ciprofloxacin, increasing the risk of developing SJS. Literature review revealed that ciprofloxacin is metabolized primarily by CYP1A2 with partial CYP3A4 metabolism, while grapefruit juice is strictly an enterocyte CYP3A4 inhibitor. To the authors' knowledge, consumption of grapefruit juice has never been demonstrated to increase systemic levels of ciprofloxacin or of other fluoroquinolones. We conclude that either this is the first reported case of a grapefruit juice-ciprofloxacin interaction causing SJS, or that this is simply ciprofloxacin-induced SJS. Importantly, ciprofloxacin is not recommended by the American Urological Association for a routine vasectomy without risk factors for infection. We remind clinicians that inappropriately prescribed antibiotic prophylaxis for routine procedures can cause serious morbidity, including SJS, and should only be prescribed when indicated.