American Journal of Therapeutics | 2021
Cefazolin-Associated Hallucinations in a Young Male With Normal Renal Function.
Abstract
To the Editor: Cefazolin, a first-generation cephalosporin, does not cross the blood–brain barrier but is known to cause central nervous system toxicity. Clinical presentation of cefazolin-associated neurotoxicity primarily includes seizures and encephalopathy. Impaired renal function, old age, and excess dosage of any medication are independent risk factors for neurotoxic effects.1 Here, we describe an interesting case of cefazolin-associated hallucinations in a relatively young patient with normal renal function emphasizing physicians to be aware of an uncommon adverse effect of a common and widely used antibiotic in our health care system. To the best of our knowledge, this is the first case in the literature highlighting hallucinations as an adverse effect of cefazolin, whereas reports are showing an association of hallucinations with other cephalosporins. A 31-year-old man with a medical history of spina bifida, Chiari malformation type 2, hydrocephalus after ventriculoperitoneal shunt placement at birth, paraplegia, neurogenic bladder, recurrent urinary tract infections, depression, and multiple chronic ulcers of bilateral lower extremities presented with fever, right leg redness, and swelling for 2 days not improving on oral doxycycline. The patient was diagnosed with nonpurulent cellulitis of the right leg, initiated on intravenous cefazolin 2 g every 8 hours. The laboratory work resulted in normal creatinine clearance and the absence of leukocytosis. There was a significant clinical improvement of symptoms and physical examination findings after 6 doses of cefazolin therapy. On day 3 of hospitalization after the seventh dose of intravenous cefazolin, the patient reported having new-onset auditory and visual hallucinations. The patient reported seeing faces with blood dripping on the windows and heard voices telling him to kill himself. He had never experienced hallucinations before this. The patient did not have any history of alcohol intake or illicit drug use. The patient did not report any sleeping disturbances. His review of symptoms was negative with the absence of neck stiffness, vomiting, nausea, or fevers. The physical examination did not demonstrate neck stiffness, Kernig sign (limited by paraplegia), or evidence of meningism. The patient underwent ventriculoperitoneal shunt x-ray series suggestive of an intact ventriculoperitoneal shunt without kinking or discontinuity. The patient was evaluated by several providers including neurology, neurosurgery, psychiatry, and infectious diseases. Further workup with lumbar puncture and brain imaging was considered but not pursued because the patient did not have evidence of meningitis on examination. Psychiatry recommended discontinuation of cefazolin due to hallucinations, considered as one of the adverse effects of the medication, and advised to avoid any cephalosporin or fluoroquinolones. The patient was started on risperidone 1 mg twice daily for the hallucinations and intravenous ertapenem 1 g daily for cellulitis. The hallucinations decreased in intensity throughout hospitalization. The patient reported significant improvement of visual hallucinations on day 8 of hospitalization and complete resolution of auditory hallucinations by day 10 of hospitalization (5 and 7 days after discontinuation of cefazolin respectively). Furthermore, the patient was diagnosed with osteomyelitis of the right big toe and underwent amputation. The patient was discharged with no antibiotics and continued risperidone. The patient was followed by psychiatry as an outpatient in a month. The risperidone was stopped because he did not report any hallucinations at the follow-up visit. On reviewing the patient’s medical records from previous hospitalizations, he had received other cephalosporins including cephalexin, cefepime, and ceftriaxone in the past without any neurologic adverse effects. The patient was explained about the hallucinations as a possible adverse effect from the use of cefazolin and asked to alert physicians in the event of future hospitalizations. Cefazolin is a first-generation cephalosporin antibacterial active against streptococci, methicillin-susceptible staphylococci, and many gram-negative organisms. It is a bactericidal agent that acts by inhibition of bacterial cell wall synthesis, has a desirable duration of action with an excellent safety profile and low cost. It is indicated in the treatment of the following infections caused by susceptible isolates of the designated microorganisms: respiratory tract infections, urinary tract infections, skin and soft-tissue infections, biliary tract infections, American Journal of Therapeutics 0, 1–2 (2021)