Rhabdomyolysis, sore throat, Levofloxacin connection

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Levofloxacin rhabdomyolysis case report sore throat

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PMID: 27557756

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The connection

Sore throat → Levofloxacin → Rhabdomyolysis is a sequential chain, not a direct triad:

1. Sore throat is the reason levofloxacin gets prescribed Levofloxacin is a respiratory fluoroquinolone commonly used for upper/lower respiratory tract infections (pharyngitis, sinusitis, bronchitis, community-acquired pneumonia). A sore throat suggestive of bacterial pharyngitis or a broader respiratory infection is a typical indication that leads a clinician to start levofloxacin - several published rhabdomyolysis case reports specifically describe patients being treated for a respiratory tract infection when they developed muscle breakdown (Wu & Yang, 2023, PMID 37114513; John et al., 2016, PMID 27557756).

2. Levofloxacin can, rarely, cause rhabdomyolysis This is a recognized but uncommon class effect of fluoroquinolones (ciprofloxacin, levofloxacin, ofloxacin, norfloxacin). Per forensic/pharmacology textbook sources - The Essentials of Forensic Medicine and Toxicology lists rhabdomyolysis among the "rare reactions" of fluoroquinolones, alongside tendonitis/tendon rupture, and notes levofloxacin has shown the highest incidence of this reaction in some pharmacovigilance data.

Mechanism is not fully elucidated but proposed pathways include:

Direct myotoxic/mitochondrial injury to skeletal muscle fibers
Chelation of magnesium and disruption of muscle cell calcium homeostasis
Idiosyncratic/immune-mediated muscle injury
Increased risk when combined with statins (atorvastatin, simvastatin) - several case reports show levofloxacin precipitating rhabdomyolysis specifically in patients already on statin therapy, likely via CYP-mediated or pharmacodynamic interaction increasing statin myotoxicity (Bouchard et al., 2019, PMID 31407828; Paparoupa et al., 2014, PMID 25140181)
Risk appears higher in renal impairment/dialysis patients and the elderly (Gupta et al., 2012, PMID 22098607; Korzets et al., 2006, PMID 16968728), and there is at least one fatal case reported (Petitjeans et al., 2003, PMID 14576967)

Typical clinical picture: onset of myalgia, muscle tightness/weakness, and difficulty walking within days of starting levofloxacin (as early as after 2-3 doses in some reports), with markedly elevated creatine kinase (CK), sometimes progressing to acute kidney injury. Symptoms generally resolve after stopping the drug and giving supportive care (IV fluids, monitoring renal function).

Bottom line: Levofloxacin is the pharmacologic link - prescribed for the sore throat/respiratory infection, and in rare idiosyncratic cases it triggers rhabdomyolysis, a serious but uncommon adverse effect of the fluoroquinolone class. If someone develops new muscle pain, weakness, dark urine, or difficulty walking while on levofloxacin (especially if also taking a statin or if they have renal impairment), the drug should be stopped and CK/renal function checked promptly.

Wu M, Yang D. Levofloxacin-induced acute rhabdomyolysis: A case report. Int J Clin Pharmacol Ther. 2023 (PMID 37114513)
John F, Oluronbi R, Pitchumoni CS. Levofloxacin-induced rhabdomyolysis: a case report. J Med Case Rep. 2016 (PMID 27557756)
Bouchard J et al. Levofloxacin-induced rhabdomyolysis in a patient on concurrent atorvastatin. J Clin Pharm Ther. 2019 (PMID 31407828)
The Essentials of Forensic Medicine and Toxicology, 36th ed., p. Quinolones and Fluoroquinolones section

Note: I did not find recent (2-year) systematic reviews or meta-analyses specifically on this topic - available evidence is limited to individual case reports, so causality is based on temporal association and rechallenge/dechallenge patterns rather than large controlled trials.

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