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\begin{document}

\title{A rare case of Levofloxacin related Iliopsoas and Achilles tendon
rupture}



\author[1]{Prabhjot  Bedi}%
\author[2]{Kiran Kuriakose}%
\author[1]{Jay Kim}%
\author[1]{Paul Lewis}%
\author[1]{Vikas Singh}%
\affil[1]{UPMC East}%
\affil[2]{UPMC McKeesport}%


\vspace{-1em}



  
  \date{May 22, 2024}


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\begin{abstract}
Achilles tendon rupture is a well-documented adverse effect of
Fluoroquinolones; however, herein we present a case of complete
iliopsoas and Achilles, and partial semimembranosus tendon rupture
secondary to Levofloxacin.%
\end{abstract}%



\sloppy


\textbf{Title:} A rare case of Levofloxacin related Iliopsoas and
Achilles tendon rupture

\textbf{Running title:} Levofloxacin related Iliopsoas and Achilles
tendon rupture

\textbf{Authors:}

Prabhjot Singh Bedi\textsuperscript{1}, Kiran
Kuriakose\textsuperscript{2}, Jay Kim\textsuperscript{1}, Paul B
Lewis\textsuperscript{3}, Vikas K Singh\textsuperscript{1}

\begin{enumerate}
\tightlist
\item
  Department of Medicine, UPMC East, Monroeville, PA, 15146
\item
  Department of Medicine, UPMC McKeesport, PA, 15132
\item
  Department of Radiology, UPMC East, Monroeville, PA, 15146
\end{enumerate}

\textbf{Corresponding Author:}

Prabhjot Singh Bedi, MD, FACP, FHM

Hospitalist, UPMC East, UPP-CCHM

Hospitalist office, Suite 0174A

2775 Mosside Blvd,

Monroeville, PA, 15146

Email: bedips@upmc.edu

\textbf{Author contributions:}

PSB and KK design and framing of manuscript, literature review

PBL Images

JK and VKS reviewing editing and literature review

\textbf{Keywords:} Levofloxacin, Iliopsoas, Achilles, Tendon rupture,
multiple tendon rupture

\textbf{Conflict of interest:} None

\textbf{Key Clinical Message:}

Achilles tendon rupture is a well-documented adverse effect of
Fluoroquinolones; however, herein we present a case of complete
iliopsoas and Achilles, and partial semimembranosus tendon rupture
secondary to Levofloxacin.

\textbf{Case presentation:}

74-year-old male with past medical history of obstructive sleep apnea,
GERD presented with pain in left hip for 2 days. It was preceded by a
pop felt while lifting a heavy steel bar. Two months prior to this he
was treated for bronchitis with prednisone and levofloxacin, but the
course was cut short a week into treatment as the patient developed pain
in his right ankle, right shoulder and left hip. Physical examination
was significant for tenderness of left hip; tenderness and palpable dell
right Achilles. MRI revealed a full thickness tear of left iliopsoas
tendon (Figure 1, 2) and right Achilles tendon (Figure 3), as well as a
low-grade partial tear of right semimembranosus tendon origin (Figure
4). Patient was managed conservatively. He was recommended to weight
bear as tolerated, continue physical therapy and follow up closely with
orthopedics. Fluoroquinolones mediated tendinopathy commonly affects
weightbearing joints which are subjected to greater mechanical
force.\textsuperscript{1} Nearly 90\% of fluoroquinolone-associated
tendinitis and tendon rupture cases involve the Achilles tendon with
bilateral involvement in up to 50\% of cases. \textsuperscript{2} To our
knowledge our case is first reported case of concomitant full thickness
Achilles and Iliopsoas, and partial semimembranosus tendon rupture.

\textbf{Figure/Legend:}

1. Coronal T2 MR image of the left hip with fat saturation demonstrating
the iliopsoas tendon with the torn aspect surrounded by edema (*).

2. Left hip oblique-axial T2 MR image with fat saturation at the bare
lesser trochanter with surrounding edema (*). A portion of the iliopsoas
tendon stump is visible in this image.

3. Sagittal fast spin echo STIR MR image of the right ankle. The
full-thickness rupture of the Achilles tendon at the myotendinous
junction is noted by the edematous cleft (*). This gap measures 2 cm.
The paratenon (red arrows) remains intact. An os trigonum (OT) is
incidentally noted.

4. Axial T2 MR image of the pelvis with multiple findings, including
right greater trochanter bursal distention, partial tear of the right
semimembranosus tendon at its ischial attachment and the left iliopsoas
tendon stump with surrounding edema (*) that tracks posteriorly towards
the lesser trochanter.

\textbf{References:}

1) Lewis, T., \& Cook, J. (2014). Fluoroquinolones and tendinopathy: a
guide for athletes and sports clinicians and a systematic review of the
literature.~\emph{Journal of athletic training} ,~\emph{49} (3),
422--427. https://doi.org/10.4085/1062-6050-49.2.09

2) Kim G. K. (2010). The Risk of Fluoroquinolone-induced Tendinopathy
and Tendon Rupture: What Does The Clinician Need To Know?.~\emph{The
Journal of clinical and aesthetic dermatology} ,~\emph{3} (4), 49--54.\selectlanguage{english}
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