Inhaled Levofloxacin Associated With Recurrent Muscle and Joint Pain in a Cystic Fibrosis Patient: Case Report
UK: A case report published in Respiratory Medicine has highlighted a potential link between inhaled levofloxacin and recurrent musculoskeletal pain in a patient with cystic fibrosis (CF). A 26-year-old woman developed diffuse muscle and joint pain exclusively during inhaled levofloxacin treatment cycles, with symptoms consistently resolving after the drug was discontinued. The findings underscore the need for clinicians to consider inhaled fluoroquinolone toxicity when evaluating unexplained musculoskeletal complaints in patients with CF.
The report was authored by Sayed Alwadaei from Hull University Teaching Hospitals NHS Trust, UK, and colleagues. Inhaled levofloxacin is commonly prescribed for people with cystic fibrosis who have chronic Pseudomonas aeruginosa infection. The therapy is generally regarded as safe, with bronchospasm and altered taste among the most frequently reported adverse effects. Evidence of systemic toxicity from inhaled levofloxacin, however, remains limited.
The authors described the case of a 26-year-old woman with cystic fibrosis carrying the G542X/2184insA genotype and chronic Pseudomonas aeruginosa colonization. As her genetic profile made her ineligible for currently available CFTR modulator therapies, her management relied on long-term alternating inhaled antibiotic treatment to control recurrent respiratory infections and progressive lung disease.
During inhaled levofloxacin treatment, the patient developed recurrent diffuse muscle and joint pain that occurred only during treatment cycles and resolved after the drug was stopped. The symptoms did not recur following permanent discontinuation, and she had previously tolerated inhaled colistimethate sodium without similar adverse effects.
The consistent pattern of symptom onset during levofloxacin therapy and resolution after withdrawal strongly suggested a probable drug-related adverse effect rather than disease progression. The authors noted that although inhaled levofloxacin is designed to limit systemic exposure, measurable systemic absorption may occur and could contribute to musculoskeletal toxicity in susceptible patients.
Fluoroquinolones are known to cause musculoskeletal adverse effects, including tendon disorders, muscle pain, and joint pain, when administered systemically. However, such complications have rarely been documented with inhaled formulations. This report adds to the limited evidence suggesting that inhaled levofloxacin may also produce systemic musculoskeletal toxicity despite its predominantly local route of delivery.
The authors emphasized that early identification of this potential adverse reaction is important because prompt discontinuation of the drug may prevent unnecessary investigations and prolonged patient discomfort. They advised clinicians to maintain a high index of suspicion when patients receiving inhaled levofloxacin report unexplained arthralgia or myalgia, particularly if symptoms follow a cyclical pattern corresponding to treatment courses.
The researchers concluded that although musculoskeletal adverse effects associated with inhaled levofloxacin appear to be uncommon, this case demonstrates a probable association supported by a clear temporal relationship and symptom resolution after drug withdrawal. They called for greater clinical awareness of this potential adverse effect and encouraged appropriate patient counseling and monitoring during treatment.
Reference:
Alwadaei, S., Allsup, N., & Shiferaw, D. (2026). Musculoskeletal adverse effects associated with inhaled levofloxacin in a patient with cystic fibrosis: A case report. Respiratory Medicine, 261, 108926. https://doi.org/10.1016/j.rmed.2026.108926
Next Story