Unexplained hepatitis following halothane

Methods for reducing non-specific antibody binding in enzyme-linked immunosorbent assays

Enzyme-linked immunosorbent assays were used to study (i) binding of rabbit antibodies (raised against litter mate liver plasma membrane fraction) to the immunizing membrane fraction, and (ii) binding of human antibodies to liver membrane fractions and to liver-specific lipoprotein (a liver membrane-derived antigen complex). When assays were conducted using the non-ionic detergent Tween 20 as blocking agent, high non-specific binding was encountered. With the low titre rabbit antisera high binding of non-immune test antibody and of second antibody (anti-rabbit IgG) to the immunogen, and also directly to the solid phase, was found. This was abolished by replacement of Tween 20 in the antibody diluent buffers by a non-reactive protein, casein proving to be a more effective blocking agent than either bovine serum albumin or gelatin. With human sera, high binding of human IgG to the solid phase was noted. This too was blocked by casein, but only when the anti-microbial agent Thimerosal was included in the casein buffer, and when Tween 20 in the wash buffer was replaced by casein-Thimerosal so that the solid phase was exposed to casein before incubation with the test serum. The casein buffers described may prove of general value in solid-phase assays where high non-specific binding is encountered.

Drug-induced hepatitis associated with anticytoplasmic organelle autoantibodies

A study from five hepatology units documenting 157 cases of drug-induced hepatitis and a second study from a laboratory of immunology which tested more than 100,000 sera permitted us to establish the frequency of antiorganelle antibodies and their diagnostic value in drug-induced hepatitis. In drug-induced hepatitis caused by a heterogenous group of drugs consisting of ajmaline, aminopterine, isaxonine, isoniazid, perhexiline, phenylbutazone and troleandromycine, antiorganelle antibodies were absent or rare. In drug-induced hepatitis caused by another heterogenous group of drugs, including clometacin, fenofibrate, oxyphenisatin and papaverine, antismooth muscle, antinucleus and antimitochondria antibodies were found in isolation or in different combinations in 70% of cases. From the presence of antismooth muscle antibodies in sera, we could trace 30 cases of clometacin-induced hepatitis. The third group included drug-induced hepatitis with special antibody:iproniazid-induced hepatitis with antimitochondrial antibody 6 and tienilic acid (ticrynafen)-induced hepatitis with antiliver/kidney microsome antibody 2 (anti-LKM2). These two antibodies are rare in routine sera and were absent in patients who received the drug and had no liver damage. From the presence of corresponding antibodies, we detected six cases of iproniazid-induced hepatitis and 67 cases of tienilic acid-induced hepatitis. Antiorganelle antibodies found in high titers disappeared in 2 to 24 months following withdrawal of the offending drug. The fourth group was represented by halothane-induced hepatitis; antiliver/kidney microsome antibody 1 was weak and infrequent. Similarities between drug-induced hepatitis of the second group and lupoïd hepatitis suggest that drugs may reveal this spontaneous disorder.(ABSTRACT TRUNCATED AT 250 WORDS)

HLA antigens in patients with unexplained hepatitis following halothane anesthesia

We examined HLA-A,B,C and DR locus antigens in 38 Japanese patients who had recovered from halothane hepatitis. The patients were divided into two subgroups, i.e. jaundice and non-jaundice groups, because the clinical features were quite different in each. DR2 was positive in 14 (58.3%) of 24 patients with jaundice, compared with 281 (33.6%) of the 837 Japanese healthy controls (chi-square with Yates' correction = 5.30, relative risk = 2.77, P less than 0.025). Conversely, Bw44 was increased in non-jaundice patients (50.0%), compared with 157 (12.7%) of the 1234 Japanese healthy controls (chi-square with Yates' correction = 13.75, relative risk = 6.86, P less than 0.001). The haplotype frequency (Hf) of Aw24-Bw52-DR2 was high in the patients with jaundice (Hf = 0.2362), while it was zero in the patients without jaundice (P less than 0.0042). These data suggest that the two groups of halothane hepatitis have different genetic backgrounds.

An enzyme-linked immunosorbent assay for detection of antibodies against halothane-altered hepatocyte antigens

Patients with massive liver cell necrosis that may follow halothane anaesthesia have a high incidence of circulating antibodies against halothane-induced hepatocyte antigens. In order to provide an objective and quantitative method for the detection of these antibodies, an enzyme-linked immunosorbent assay has been developed. Sera, after absorption with normal rabbit liver microsomal fraction, are tested for binding to microsomal fractions from control and halothane-pretreated rabbits. Those containing antibodies against halothane-induced determinants give significantly enhanced binding to halothane-altered fractions; this specificity was verified by absorption experiments. Using this method, halothane-related antibodies were detected in sera from 16/24 patients with halothane-associated liver failure, at titres ranging from 1:100 to 1:25600. Such antibodies were not detectable in sera from 26 normal blood donors, 5 healthy anaesthetists, 12 patients who had received multiple halothane anaesthetics but had normal liver function tests and 32 patients with a variety of other liver diseases. This rapid and reproducible assay should be of value for the detection of antibodies and for detailed investigation of patient antibody responses, and also for characterization of the route of production and metabolism of the antigen.

A new anti-liver-kidney microsome antibody (anti-LKM2) in tienilic acid-induced hepatitis

The sera of 131 patients with anti-liver-kidney microsome antibodies (anti-LKM) detected between 1973 and 1979 in two different laboratories were re-examined. (1) Eighty-six anti-LKM corresponded to the description given by Rizzetto, Swana & Doniach (1973), with a pattern of fluorescence predominating on the 3rd portion of the proximal tubules (P3). This group comprised 45 cases of idiopathic chronic hepatitis or idiopathic cirrhosis and one case of halothane-induced hepatitis. (2) Forty-five anti-LKM gave a different pattern on male mouse liver and male rat kidney: (a) fluorescence was greater on centrolobular than on periportal hepatocytes; (b) the first and second portions of proximal tubules (P1 and P2) predominated over P3; (c) P1 fluorescence was equally intense as P2 and (d) P3 cells were heterogeneous with one cell out of 20 more positive than the rest. Absorption tests confirmed that the corresponding antigen was also present in the liver microsomal fraction. A retrospective clinical study discovered tienilic acid-induced hepatitis in all cases. We suggest naming this new antibody 'anti-LKM2'.

[Post-anesthetic hepatitis. The role of halothane and antimitotic combinations]

A 12 year old boy with Burkitt's lymphoma developed severe hepatitis with hepatomegaly, subclinical jaundice, and a small rise in body temperature, associated with an important rise in SGPT and fall in prothrombin titres, 6 days after anticancer chemotherapy and 24 hours after halothane anaesthesia. Hepatitis A and B serology remained negative. This hepatic failure explained perhaps the unusually severe vincristine toxicity which gave rise to a polyneuritis with important sequelae. The association of halothane hepatitis with antimitotic drugs appeared particularly dangerous, and halothane should probably be avoided in all patients been given or about to be given anticancer chemotherapy.

Liver cell surface expression of the antigen reacting with liver-kidney microsomal antibody (LKM)

To test the hypothesis that liver membrane antibodies, found in all liver-kidney microsomal antibody (LKM) positive sera from patients with chronic active hepatitis, were directed against antigens shared by both hepatocellular endoplasmic reticulum and plasma membranes, absorption experiments have been performed using viable isolated hepatocytes and liver microsomes as antigens. Results are in agreement with the above hypothesis, LKM, which displays a restricted organ specificity, is thus able to react with antigenic determinants expressed on the liver cell surface, as it has been demonstrated for strictly organ specific antibodies directed against thyroid, adrenal and gastric parietal cell microsomes.

A new antimitochondria antibody (anti-M6) in iproniazid-induced hepatitis

A new immunofluorescence pattern of non-organ- and non-species-specific antibody has been observed in occasional sera. Variations of the fluorescence were found in different species. Recognition of the new pattern was particularly characteristic in rat organs (liver: the hepatocytes showed intense roughly granular fluorescence evenly distributed in the cytoplasm; kidney: the bright fluorescence of the first portion of the proximal tubules contrasted with the negative aspect of the other portions of the tubules; stomach: only some cells probably corresponding to the APUD system were positive; pancreas: fluorescence was limited to the islets of Langherhans). The positivity in the ellipsoid region of the rods and cones of the eye and the absorption on different liver organelles showed that this aspect corresponded to the mitochondria. We propose to name this pattern 'antimitochondria antibody number 6' or 'anti-M6'. High titres of anti-M6 were found in four patients suffering from iproniazid-induced hepatitis. A decrease in the titre was obtained after stopping the treatment. The now exceptional use of iproniazid and the rare occurrence of anti-M6 suggest a link between these two phenomena.

Campylobacter jejuni colitis in gnotobiotic dogs

Campylobacter jejuni of human and canine origin was inoculated orally into six gnotobiotically reared Beagle puppies and reactions were compared with two controls. Inoculated dogs developed transient lassitude, inappetence, mild diarrhea and tenesmus during the period 36-72 hours after inoculation. Pairs of dogs killed 43 hours, and five and seven days after inoculation had lesions limited to typhlitis and colitis. Congestion of colonic mucosa, associated loss of goblet cells, attenuation and exfoliation of surface epithelium with microerosions, hypertrophy of glands and neutrophil infiltration of lamina propria were seen during the acute phase. Less severe surface and inflammatory lesions were evident at five and seven days, with hyperplasia of the proliferative compartment in mucosal glands. Campylobacter established at over 10(10) organisms per gram of colonic content but did not invade the mucosa. It was concluded that the gnotobiotic dog may be a suitable model for investigation of the pathogenesis of Campylobacter colitis.

Oxidative metabolism of halothane in the production of altered hepatocyte membrane antigens in acute halothane-induced hepatic necrosis

Previous investigations have shown that patients with fulminant hepatic failure after halothane anaesthesia have a circulating antibody which reacts with an antigen present on the surface of halothane-altered hepatocytes. In the present study, it has been shown that the expression of the antigen is associated with the oxidative metabolism of halothane, in contrast with results of other groups which have shown that the reductive route is involved in the direct hepatotoxic reaction attributed to halothane.

Antibodies to the surface of halothane-altered rabbit hepatocytes in patients with severe halothane-associated hepatitis

Circulating antibodies reacting specifically with the cell membrane of hepatocytes isolated from halothane-anesthetized rabbits were detected in nine of 11 patients with fulminant hepatic failure after helothane-induced anesthesia. The immunoglobulin deposition, as revealed by immunofluorescence, showed a granular pattern on the hepatocyte surface membrane. Preincubation of halothane-pretreated, but not of control, hepatocytes with serum containing this antibody rendered them susceptible to cytotoxic effects of normal lymphocytes in vitro. Control studies using serum from subjects repeatedly exposed to halothane without the development of liver damage, and from patients with viral and toxic liver injury have confirmed the specificity of these findings to serve halothane-associated liver injury. These results provide further evidence of an immunologic component in this condition.

Hepatic necrosis in rats following halothane administration: protective effect of diethyldithiocarbamate

Foci of necrosis have been observed in the liver of 50% of enzyme-induced rats treated with halothane. The frequency of liver necrosis was significantly reduced by treatment with the free radical scavenger diethyldithiocarbamate. The severity of the lesion was not increased by repeated exposures to the anesthetic, and, although the frequency of liver necroses may be greater, the differences were not statistically significant.

Hepatotoxicity and halothane metabolism in an animal model with application for human toxicity

Centrilobular necrosis and a ten-fold elevation in serum alanine amino-transferase (ALT) consistently followed 2 hours of 1% halothane anaesthesia in an animal model. Conditional factors were the presence of enzyme induction and moderate hypoxia (14% oxygen), indicating an association between reductive metabolism and hepatotoxicity. Under these conditions there was at least a four-fold increase in reductive metabolites detected in the exhaled air. In clinical studies, reductive metabolites were also detected in the exhaled air of all patients examined, even after halothane anaesthesia with 100% oxygen. The amounts of reductive metabolites were comparable in man and the model, following equivalent halothane doses. It appears that a model with a similar route and rate of halothane biotransformation to man has been identified. The lesion of halothane hepatotoxicity in this model appears to be similar to that reported in man - centrilobular hepatic necrosis.

Jaundice after repeated exposure to halothane: a further analysis of reports to the Committee on Safety of Medicines

Aanalysis of data derived from 170 reports of jaundice developing after anaesthesia with halothane received after January 1974 confirmed the relations between multiple exposure to halothane and jaundice and between the number of exposures and the rapidity with which jaundice develops after exposure. When these reports were combined with 130 received earlier complete anaesthetic histories were available for 251 patients, 205 (82%) of whom had been exposed to halothane more than once; of these patients, 154 (75%) had been exposed more than once within 28 days. Altogether 139 (46%) of the 300 patients died.

Recurrent hepatitis following halothane exposures

The existence of hepatotoxicity due to halothane remains subject to debate. Three cases are presented in which multiple exposures to halothane were followed in several instances by evidence of postoperative fever and/or hepatitis. In one case, hepatitis with bridging necrosis developed; the patient responded to long-term steroid therapy. In another, fulminant hepatic necrosis proved fatal. A brief review of halothane hepatitis is given. Otherwise unexplained fever and hepatitis following the use of halothane, especially if recurrent or accompanied by evidence of hypersensitivity, should contraindicate subsequent use of that drug.

A morphologic study of unexplained hepatitis following halothane anesthesia

A survey of postoperative jaundice throughout the United Kingdom allowed the detailed analysis of 76 patients with unexplained hepatitis following halothane anesthesia ("halothane hepatitis"). In 16 patients liver biopsy specimens were examined by light and/or electron microscopy to determine whether the liver morphology could aid the differentiation between "halothane" and "acute viral" hepatitis. The mitochondrial changes often claimed to be characteristic of holothane hepatitis were unremarkable in our patients. Since lipid vacuolation and a predominantly centrilobular distribution of necrosis are not classically described in fatal viral hepatitis, the presence of these features in some of our fatal cases was of some diagnostic interest. In general, however, the results of light and electron microscopy in patients with unexplained postoperative hepatitis is considered to have little differential diagnositc value.

Halothane hepatitis

Halothane (2-bromo-2-chloro-1:1:1-trifluoroethane) is a volatile, nonflammable anaesthetic agent which has been widely used for the last 20 years. Halothane hepatitis has been a matter of continuing controversy, but now it seems to be generally accepted as a clinical entity. Characteristically the halothane hepatitis occurs after multiple exposures to halothane within short time. The pathogenesis of the liver cell damage is obscure. It is estimated that the incidence of halothane hepatitis is about one per 8000 halothane anaesthesias and the lethality about one per 40000. Prophylaxis consists of avoiding repeated halothane anaesthesias within short time and to avoid re-exposure to halothane if otherwise unexplained liver damage has occurred after halothane.

Circulating immune complexes after repeated halothane anaesthesia

A patient developed hepatitis after receiving three halothane anaesthetics in 22 days. Twenty-four hours after the onset of jaundice she developed an acute serum sickness syndrome with polyarthralgia, proteinuria, and transient impairment of renal function. Serum concentrations of complement components C1q, C4, and C3 were substantially reduced, and immune complexes capable of activating the complement system via the classical pathway were present in the serum and synovial fluid. A metabolite of halothane was associated with these complexes. Fourteen months after exposure to halothane her lymphocytes were stimulated in vitro by this metabolite. The conditions under which stimulation occurred were unusual--namely, a 7S fraction of the serum, presumably IgG, was necessary. Our results provide strong evidence that halothane may be immunogenic and that its immunogenicity is dependent on the non-covalent binding of one of its metabolites to plasma proteins.

Ketamine and paediatric radiotherapy

Two hundred and seventy-two ketamine anesthetics have been given to sixteen children undergoing radiotherapy. Satisfactory conditions were provided in every case and the incidence of complications was low. At the present time ketamine would appear to be the most satisfactory agent in thos children who require sedation in order to undergo radiotherapy.

Halothane macrophage migration inhibtiion factor test in halothane-associated hepatitis

As an index of delayed hypersensitivity in vitro halothane macrophage migration inhibition factor tests (halothane-MIF tests) were performed on peripheral blood lymphocytes from five patients with halothane hepatitis. Twenty-two subjects exposed to halothane, but with no evidence of jaundice, five 'healthy' hospital anaesthetists, nine jaundiced subjects without halothane exposure, and 10 healthy subjects with no history of exposure to halothane were also tested. The halothane-MIF test was positive in four of the five patients with halothane-induced hepatitis; the negative result was in a patient on steroid treatment. The test was negative in all other subjects. Our findings suggest that the halothane-MIF test may be of value in the diagnosis of halothane-induced hepatitis and as a screeening procedure for the identification of susceptible subjects.

Hepatic and gastrointestinal disorders in pregnancy

The presentation, nonradiologic diagnostic evaluation, and course (including complications and outcome) of gastrointestinal disorders in pregnancy are not substantially different than for the nonpregnant patient. The possible exception is the higher mortality for pancreatitis when it occurs during pregnancy. With the exception of nausea/vomiting and hyperemesis gravidarum, there does not appear to be a gastrointestinal tract disorder that is peculiar to the pregnant state. Hepatic disorders are somewhat different in that the excretory defect-pruritus gravidarum-cholestatic jaundice spectrum and perhaps part of what presents as acute hepatic failure are intimately associated with pregnancy and have an onset and course that are tied to the gestational period. Otherwise, hepatic diseases that occur during pregnancy share the characteristic of gastrointestinal diseases, that their manifestations are not clearly different from the nonpregnant state. As is true for the diagnostic approach to all medical diseases that occur during pregnancy, radiographic procedures are prohibited. Furthermore, therapy must be reconsidered with concern for its effect on the fetus. This leads to elimination of many or all measures used for purely symptomatic or nonspecific benefit. If no harm or potential harm will accrue for the fetus, therapy for hepatic and gastrointestinal disorders preceeds in pregnancy very much as it does in the nongravid individual.