Hepatic failure and lactic acidosis due to fialuridine (FIAU), an investigational nucleoside analogue for chronic hepatitis B

BACKGROUND

We describe severe and unexpected multisystem toxicity that occurred during a study of the antiviral nucleoside analogue fialuridine (1-(2-deoxy-2-fluoro-beta-D-arabinofuranosyl)-5-iodouracil, or FIAU) as therapy for chronic hepatitis B virus infection.

METHODS

Fifteen patients with chronic hepatitis B were randomly assigned to receive fialuridine at a dose of either 0.10 or 0.25 mg per kilogram of body weight per day for 24 weeks and were monitored every 1 to 2 weeks by means of a physical examination, blood tests, and testing for hepatitis B virus markers.

RESULTS

During the 13th week lactic acidosis and liver failure suddenly developed in one patient. The study was terminated on an emergency basis, and all treatment with fialuridine was discontinued. Seven patients were found to have severe hepatotoxicity, with progressive lactic acidosis, worsening jaundice, and deteriorating hepatic synthetic function despite the discontinuation of fialuridine. Three other patients had mild hepatotoxicity. Several patients also had pancreatitis, neuropathy, or myopathy. Of the seven patients with severe hepatotoxicity, five died and two survived after liver transplantation. Histologic analysis of liver tissue revealed marked accumulation of microvesicular and macrovesicular fat, with minimal necrosis of hepatocytes or architectural changes. Electron microscopy showed abnormal mitochondria and the accumulation of fat in hepatocytes.

CONCLUSIONS

In patients with chronic hepatitis B, treatment with fialuridine induced a severe toxic reaction characterized by hepatic failure, lactic acidosis, pancreatitis, neuropathy, and myopathy. This toxic reaction was probably caused by widespread mitochondrial damage and may occur infrequently with other nucleoside analogues.

Function of hisF and hisH gene products in histidine biosynthesis

A mutant of the enterobacterium Klebsiella pneumoniae with a defect in the hisF gene (in the histidine biosynthesis pathway) was isolated, which can only grow with high but not low ammonia concentrations. The mutated hisF product can use ammonia for the formation of the imidazole ring of histidine but not glutamine provided by the hisH product. Site-directed insertional mutagenesis of hisH led to the same dependence of prototrophic growth on high ammonia levels. The nucleotide sequence of K. pneumoniae hisF is almost identical to that of hisF from other enterobacteria. Similarities of the hisF product with the hisA product and of HisH sequences with the glutamine binding domains of TrpG-type amidotransferases provide additional evidence for the functions of the hisF and hisH products in histidine biosynthesis, namely that HisF catalyzes the ammonolytic cleavage of N'-(5'-phosphoribulosyl)-formimino-5- aminoimidazole-4-carboxamide ribonucleotide either utilizing free ammonia or deriving the ammonia moiety from glutamine bound to HisH.

[Sequelae of cannabis use--results of a survey of experts on traffic accidents and "echopsychoses" (flash-back)]

There is a lack of knowledge in the judgement of the effects and the dangerousness of cannabis. Specially in the judgement of the delinquency of traffic the effects must be clarified. Cannabis plays often a fundamental role in road accidents. Obviously flash-backs of consumers of cannabis are observed more often than documented in the literature hitherto. The existing but not published experiences of experts have to be considered extensively to get an idea more complete of the diverse effects of cannabis in traffic offences.

Genetic analysis of the regulatory putP region (coding for proline permease) in Klebsiella pneumoniae M5a1: evidence for regulation by the nac system

During a search for nitrogen-controlled promoters on the Klebsiella pneumoniae M5a1 chromosome, the regulatory region of putP (coding for proline permease) was cloned, sequenced and analyzed. The region contained a weak sigma 70-dependent promoter and putative binding sites for the cAMP-CAP complex and the Nac regulatory protein, the latter probably providing a link with the nitrogen regulation (Ntr) system. Using a lacZ gene fusion, evidence for control of putP transcription by both Nac and Ntr was obtained.

Fazarabine: a report of response in a patient with multiply relapsed embryonal cell carcinoma

This report describes a patient with multiply relapsed and advanced metastatic embryonal cell carcinoma who achieved a pathological partial remission (PR) following treatment with a Phase I chemotherapeutic agent, arabinosyl-5-azacytosine (Ara-AC), followed by orchiectomy. The antimetabolic Ara-AC is worthy of further study in patients with germ-cell tumors. It would appear that the antimetabolite Ara-AC may have significant activity in patients with germ-cell tumors.

High plasma clozapine levels in tardive dyskinesia

Studies in the literature that attempt to relate neuroleptic plasma levels to the development of tardive dyskinesia (TD) report inconsistent findings. As part of an open, long-term study, 60 schizophrenic and schizoaffective patients were started gradually on a b.i.d. schedule of the atypical antipsychotic drug clozapine. Blood samples were drawn weekly for 6 weeks and analyzed for a variety of constituents including clozapine plasma levels. Patients with higher levels of TD were found to have significantly higher levels of plasma clozapine and a higher ratio of plasma/dose than those with lower levels of TD. Our data suggests that schizophrenics with TD may have different pharmacokinetics, drug metabolism, and elimination processes than those without TD. Higher typical plasma neuroleptic levels may increase susceptibility to TD development. A second hypothesis implies that it is not the higher mean plasma level of a neuroleptic that is associated with TD but the greater fluctuations of plasma levels over time (i.e., a higher variance). This hypothesis is discussed in the context of our data.

The gltF gene of Klebsiella pneumoniae: cloning and initial characterization

From a gene bank of Klebsiella pneumoniae M5a1, a 1.7 kb gene fragment was isolated which was able to restore the Ntr+ phenotype and ammonium (methylammonium) transport, but not glutamate synthase in an Escherichia coli glt mutant (glutamate synthase deficiency). The fragment strongly hybridized with the gltF regulatory gene from E. coli. After subcloning the fragment into an overexpression vector, a protein with a molecular weight of 27,000 dalton was identified as the gene product. The results indicate that the fragment cloned contains the gltF gene from K.pneumoniae.

Dismutation of hydroxylamine to ammonia and nitrite by a novel, membrane-bound enzyme from the cyanobacterium Phormidium uncinatum

Extracts from ammonium-grown phototrophic cultures of Phormidium uncinatum exhibited a catalytic and stoichiometric formation of nitrite and ammonia from hydrogen peroxide and hydroxylamine. This reaction was due to a novel enzyme (referred to as hydroxylamine dismutase), which was bound to the heavier thylakoid membranes. The enzyme was solubilized from the membranes by detergent treatment and further purified by ion-exchange chromatography. On the basis of inhibitor studies, the involvement of metal ions and sulfhydryl groups in the characteristic reaction is suggested.

Assimilation of methylamine by Paracoccus denitrificans involves formaldehyde transport by a specific carrier

Assimilation of methylamine by Paracoccus denitrificans involves the following enzymes: a periplasmic methylamine dehydrogenase, a formaldehyde transport system, cytoplasmic formaldehyde and formate dehydrogenase. Formaldehyde transport follows saturation kinetics with a high substrate affinity (Km = 7 microM), and is severely inhibited by iodoacetate, cyanide and p-trifluoromethoxy carbonylcyanide phenylhydrazone. Expression of the formaldehyde carrier is regulated by the carbon source.

Construction of multicopy expression vectors for regulated over-production of proteins in Klebsiella pneumoniae and other enteric bacteria

A number of expression vectors have been constructed to allow over-production of selected gene products in Klebsiella pneumoniae and other enteric bacteria. The plasmids use the strong hybrid trp-lac (tac) promoter for gene expression, which is regulated by the lacIQ allele of the lac repressor carried on the vector. This provides very tight regulation of gene expression, which is important for over-production of proteins which may be detrimental to cell growth. The vectors carry the standard mp18 cloning nest in which all the restriction sites are unique to the plasmid (with the exception of EcoRI in pDK7). Derivatives were constructed carrying kanamycin, chloramphenicol or ampicillin resistance as selectable markers, the first two of which are advantageous in K. pneumoniae due to the high inherent beta-lactamase activity of this organism.

N2 fixation and NH4+ assimilation in the thermophilic anaerobes Clostridium thermosaccharolyticum and Clostridium thermoautotrophicum

Inorganic nitrogen metabolism in the obligate anaerobic thermophiles Chlostridium thermosaccharolyticum and Clostridium thermoautotrophicum differs in several respects. C. thermosaccharolyticum contains a nitrogenase as inferred from NH4+ repressible C2H2 reduction, a glutamine synthetase which is partially repressed by ammonium, very labile glutamate synthase activities with both NADH and NADPH, NADPH-dependent glutamate dehydrogenase, and NH4+-dependent asparagine synthetase. C. thermoautotrophicum contains no nitrogenase, but glutamine synthetase, no glutamate synthase, no glutamate dehydrogenase, but a NADH-dependent alanine dehydrogenase and a NH4+-dependent asparagine synthetase.

Energy expenditure for cyclic retention of NH3/NH4+ during N2 fixation by Klebsiella pneumoniae

The permeability coefficient for NH3 through bacterial membranes was determined to be around 2 X 10(-3) cm X s-1. This value was used to calculate the outward diffusion of NH3 from intracellular pools and the energy costs for reabsorption as NH4+. For an N2-fixing continuous culture of Klebsiella pneumoniae an energy expenditure of around 4 ATP per NH3 produced was calculated, thus increasing significantly the energy requirement for N2 fixation in vivo.

Some properties of a Klebsiella pneumoniae ammonium transport negative mutant (Amt-)

The main property of an Amt- (ammonium transport negative) mutant of Klebsiella pneumoniae is its inability to accumulate NH4+ intracellularly. When growing on nitrogen sources other than NH4+, the mutant constantly looses NH3 by diffusion. This loss results in poor growth. The NH3 excretion suggests the existence of a futile cycle (NH3 loss/NH4+ reabsorption) in the wild type and possibly other bacterial strains, which do not constantly excrete NH3.

Uptake of methionine sulfoximine by some N2 fixing bacteria, and its effect on ammonium transport

The N2 fixing bacteria Klebsiella pneumoniae, Azospirillum brasilense, Rhodopseudomonas sphaeroides and Rhodospirillum rubrum, but not Azotobacter vinelandii accumulate the glutamine analogue methionine sulfoximine in the cell. In the accumulating cells methionine sulfoximine inhibits ammonium transport. Accumulation and inhibition are prevented by glutamine.

Ammonium (methylammonium) transport by Klebsiella pneumoniae

Klebsiella pneumoniae can accumulate methylammonium up to 80-fold by means of a transport system as indicated by the energy requirement, saturation kinetics and a narrow pH profile around pH 6.8. Methylammonium transport (apparent Km = 100 microM, V = 40 mumol/min per g dry weight at 15 degrees C) is competitively inhibited by ammonium (apparent Ki = 7 microM). The low Ki value and the finding that methylammonium cannot serve as a nitrogen source indicate that ammonium rather than methylammonium is the natural substrate. Uphill transport is driven by a component of the protonmotive force, probably the membrane potential. The transport system is under genetic control; it is partially repressed by amino acids and completely by ammonium. Analysis of mutants suggest that the synthesis of the ammonium transport system is subject to the same 'nitrogen control' as nitrogenase and glutamine synthetase.

Some properties of a new electrogenic transport system: the ammonium (methylammonium) carrier from Clostridium pasteurianum

Clostridium pasteurianum is able to build up about 100-fold gradients of methylammonium across the cell membrane. Methylammonium enters the cell by means of a carrier as shown by the energy requirement, saturation kinetics and a pH profile with a narrow maximum between pH 6.2 and 6.8. The methyl ammonium transport (apparent Km = 150 microM, V = 100 mumol/min per g dry weight) is competitively inhibited by ammonium (apparent Ki = 9 microM). The low Ki value and the observation that methylammonium cannot serve as a carbon or nitrogen source for Cl. pasteurianum strongly indicate that ammonium rather than methylammonium is the natural substrate. Uncouplers and inhibitors of energy metabolism or of the membrane-bound ATPase inhibit transport. Cl. pasteurianum maintains a membrane potential (interior negative) in the range 80-130 mV. This membrane potential was identified as the energy source: the same agents that block transport also decrease the membrane potential, and artificial generation of a membrane potential (by addition of valinomycin to K+-loaded cells) induces concentrative uptake of methylammonium. Thus NH4+ (or CH3NH3+) must be the transported species. Digestion of the cell wall by lysozyme does not abolish the transport activity.