Biopsy-proved acute tubulointerstitial nephritis and toxic epidermal necrolysis associated with vancomycin

A 70-year-old man receiving vancomycin for a methicillin-resistant Staphylo coccus aureus (MRSA) abscess developed a drug-induced hypersensitivity reac tion with rash, eosinophilia, and acute renal failure requiring dialysis. R enal biopsy revealed diffuse and marked interstitial and tubular infiltrati on by mononuclear cells and eosinophils; acute tubulointerstitial nephritis (TIN) was diagnosed. The rash progressed to erythema multiforme major afte r rechallenge with vancomycin in the setting of MRSA peritoneal catheter-re lated peritonitis and then to fatal toxic epidermal necrolysis in the setti ng of steroid taper and persistent serum vancomycin levels. This case furth er implicates vancomycin as a drug that infrequently can cause severe acute TIN and exfoliative dermatitis. When a renally excreted drug such as vanco mycin is administered, serum drug levels should be serially monitored and h igh-dosage steroids be maintained or tapered slowly until serum drug levels become undetectable.