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Therapeutic Management of Idiosyncratic Drug-Induced Liver Injury and Acetaminophen Hepatotoxicity in the Paediatric Population: A Systematic Review. Drug Saf 2022; 45:1329-1348. [PMID: 36006605 PMCID: PMC9560995 DOI: 10.1007/s40264-022-01224-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2022] [Indexed: 12/15/2022]
Abstract
Introduction Drug-induced liver injury (DILI) is a rare but serious adverse event that can progress to acute liver failure (ALF). The evidence for treatment of DILI in children is scarce. Objective We aimed to comprehensively review the available literature on the therapies for both acetaminophen overdose (APAP) and idiosyncratic DILI in the paediatric population. Methods We included original articles conducted in a paediatric population (< 18 years) in which a therapeutic intervention was described to manage APAP or idiosyncratic DILI. Findings were summarized based on age groups (preterm newborn neonates, term and post-term neonates, infants, children and adolescents). Results Overall, 25 publications (fifteen case reports, six case series and four retrospective cohort studies) were included, including a total of 140 paediatric DILI cases, from preterm newborn neonates to adolescents. N-acetylcysteine was used to treat 19 APAP cases. N-acetylcysteine (n = 14), ursodeoxycholic acid (n = 3), corticosteroids (n = 31), carnitine (n = 16) and the combination of glycyrrhizin, reduced glutathione, polyene phosphatidylcholine and S-adenosylmethionine (n = 31) were the therapeutic options for treating idiosyncratic DILI. The molecular adsorbent recirculating system was used in the management of either APAP (n = 4) or idiosyncratic DILI (n = 2), while 20 paediatric ALF cases received continuous renal replacement therapy. Conclusions This systematic review identified DILI in the paediatric population who have received specific treatment. These interventions appear to be mainly extrapolated from low-quality evidence from the adult population. Thus, there is a need for high-quality studies to test the efficacy of known and novel therapies to treat DILI specifically addressed to the paediatric population. PROSPERO registration number CRD42021214702. Supplementary Information The online version contains supplementary material available at 10.1007/s40264-022-01224-w.
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Ivnitsky JJ, Schäfer TV, Rejniuk VL, Vakunenkova OA. Secondary Dysfunction of the Intestinal Barrier in the Pathogenesis of Complications of Acute Poisoning. J EVOL BIOCHEM PHYS+ 2022; 58:1075-1098. [PMID: 36061072 PMCID: PMC9420239 DOI: 10.1134/s0022093022040123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 11/22/2022]
Abstract
The last decade has been marked by an exponential increase
in the number of publications on the physiological role of the normal
human gut microbiota. The idea of a symbiotic relationship between
the human organism and normal microbiota of its gastrointestinal
tract has been firmly established as an integral part of the current
biomedical paradigm. However, the type of this symbiosis varies
from mutualism to parasitism and depends on the functional state
of the host organism. Damage caused to the organism by external
agents can lead to the emergence of conditionally pathogenic properties
in the normal gut microbiota, mediated by humoral factors and affecting
the outcome of exogenous exposure. Among the substances produced
by symbiotic microbiota, there are an indefinite number of compounds
with systemic toxicity. Some occur in the intestinal chyme in potentially
lethal amounts in the case they enter the bloodstream quickly. The quick
entry of potential toxicants is prevented by the intestinal barrier
(IB), a set of structural elements separating the intestinal chyme
from the blood. Hypothetically, severe damage to the IB caused by
exogenous toxicants can trigger a leakage and subsequent systemic
redistribution of toxic substances of bacterial origin. Until recently,
the impact of such a redistribution on the outcome of acute exogenous
poisoning remained outside the view of toxicology. The present review
addresses causal relationships between the secondary dysfunction
of the IB and complications of acute poisoning. We characterize
acute systemic toxicity of such waste products of the normal gut microflora
as ammonia and endotoxins, and demonstrate their involvement in
the formation of such complications of acute poisoning as shock,
sepsis, cerebral insufficiency and secondary lung injuries. The
principles of assessing the functional state of the IB and the approaches
to its protection in acute poisoning are briefly considered.
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Affiliation(s)
- Ju. Ju. Ivnitsky
- Golikov Research Clinical Center of Toxicology, Federal Medical Biological Agency, St. Petersburg, Russia
| | - T. V. Schäfer
- State Scientific Research Test Institute of Military Medicine, Ministry of Defense of the Russian Federation, St. Petersburg, Russia
| | - V. L. Rejniuk
- Golikov Research Clinical Center of Toxicology, Federal Medical Biological Agency, St. Petersburg, Russia
| | - O. A. Vakunenkova
- Golikov Research Clinical Center of Toxicology, Federal Medical Biological Agency, St. Petersburg, Russia
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Squires JE, Alonso EM, Ibrahim SH, Kasper V, Kehar M, Martinez M, Squires RH. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr 2022; 74:138-158. [PMID: 34347674 DOI: 10.1097/mpg.0000000000003268] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
ABSTRACT Pediatric acute liver failure (PALF) is a rare, rapidly progressive clinical syndrome with significant morbidity and mortality. The phenotype of PALF manifests as abrupt onset liver dysfunction, which can be brought via disparate etiology. Management is reliant upon intensive clinical care and support, often provided by the collaborative efforts of hepatologists, critical care specialists, and liver transplant surgeons. The construction of an age-based diagnostic approach, the identification of a potential underlying cause, and the prompt implementation of appropriate therapy can be lifesaving; however, the dynamic and rapidly progressive nature of PALF also demands that diagnostic inquiries be paired with monitoring strategies for the recognition and treatment of common complications of PALF. Although liver transplantation can provide a potential life-saving therapeutic option, the ability to confidently determine the certainness that liver transplant is needed for an individual child has been hampered by a lack of adequately tested clinical decision support tools and accurate predictive models. Given the accelerated progress in understanding PALF, we will provide clinical guidance to pediatric gastroenterologists and other pediatric providers caring for children with PALF by presenting the most recent advances in diagnosis, management, pathophysiology, and associated outcomes.
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Affiliation(s)
- James E Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Estella M Alonso
- Department Pediatric Hepatology, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois, USA
| | - Samar H Ibrahim
- Department of Pediatrics, Division of Pediatric Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vania Kasper
- Division of Pediatric Gastroenterology, Nutrition and Liver Diseases, Hasbro Children's Hospital, Providence, RI
| | - Mohit Kehar
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Mercedes Martinez
- Department of Pediatrics, Vagelos College of Physician and Surgeons, Columbia University, New York, NY
| | - Robert H Squires
- Division of Gastroenterology, Hepatology and Nutrition, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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4
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Trimethoprim-Sulfamethoxazole Associated Drug-Induced Liver Injury in Pediatrics: A Systematic Review. Pediatr Infect Dis J 2020; 39:824-829. [PMID: 32282528 DOI: 10.1097/inf.0000000000002664] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Drug-induced liver injury (DILI) is a rare but known adverse event associated with trimethoprim-sulfamethoxazole (TMP-SMX) in adults. No studies to date have looked at the risk of this association in children. We systematically reviewed the evidence for a potential association between TMP-SMX and DILI in the pediatric population. METHODS PubMed, Medline, Embase, Cochrane Database of Systematic Reviews, Scopus and Web of Science was searched using a combination of terms to identify reports of TMP-SMX exposure, liver injury and pediatrics (≤18 years old). We included any studies with hepatic adverse events occurring after exposure to TMP-SMX. Bibliographies were reviewed for additional relevant references. The Narajno scale was used to assess causality in case studies. RESULTS A total of 22 studies were identified: 3 randomized trials, 1 prospective observational study, 8 retrospective observational studies and 10 case reports. Among the randomized trials and prospective studies, only mild, transient hepatic function abnormalities were reported. Retrospective observational studies reported 1 fatal DILI and statistically significant increased odds of DILI with TMP-SMX use compared with nonuse. Among the 10 case reports, severe liver outcomes and mild hepatic function abnormalities were both reported. Naranjo scores suggested reported hepatic adverse events were probably because of exposure in 5, possible in 4, and doubtful in 1 case report. CONCLUSIONS Evidence regarding DILI associated with TMP-SMX exposure in pediatrics is limited. Observational population studies show mild hepatic abnormalities. Case reports suggest more severe manifestations of DILI. Additional studies may reveal the association between TMP-SMX and DILI in pediatrics.
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Shi Q, Yang X, Greenhaw JJ, Salminen AT, Russotti GM, Salminen WF. Drug-Induced Liver Injury in Children: Clinical Observations, Animal Models, and Regulatory Status. Int J Toxicol 2017; 36:365-379. [PMID: 28820004 DOI: 10.1177/1091581817721675] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Drug-induced liver injury in children (cDILI) accounts for about 1% of all reported adverse drug reactions throughout all age groups, less than 10% of all clinical DILI cases, and around 20% of all acute liver failure cases in children. The overall DILI susceptibility in children has been assumed to be lower than in adults. Nevertheless, controversial evidence is emerging about children's sensitivity to DILI, with children's relative susceptibility to DILI appearing to be highly drug-specific. The culprit drugs in cDILI are similar but not identical to DILI in adults (aDILI). This is demonstrated by recent findings that a drug frequently associated with aDILI (amoxicillin/clavulanate) was rarely associated with cDILI and that the drug basiliximab caused only cDILI but not aDILI. The fatality in reported cDILI studies ranged from 4% to 31%. According to the US Food and Drug Administration-approved drugs labels, valproic acid, dactinomycin, and ampicillin appear more likely to cause cDILI. In contrast, deferasirox, isoniazid, dantrolene, and levofloxacin appear more likely to cause aDILI. Animal models have been explored to mimic children's increased susceptibility to valproic acid hepatotoxicity or decreased susceptibility to acetaminophen or halothane hepatotoxicity. However, for most drugs, animal models are not readily available, and the underlying mechanisms for the differential reactions to DILI between children and adults remain highly hypothetical. Diagnosis tools for cDILI are not yet available. A critical need exists to fill the knowledge gaps in cDILI. This review article provides an overview of cDILI and specific drugs associated with cDILI.
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Affiliation(s)
- Qiang Shi
- 1 Division of Systems Biology, National Center for Toxicological Research, Food and Drug Administration, Jefferson, AR, USA
| | - Xi Yang
- 1 Division of Systems Biology, National Center for Toxicological Research, Food and Drug Administration, Jefferson, AR, USA
| | - James J Greenhaw
- 1 Division of Systems Biology, National Center for Toxicological Research, Food and Drug Administration, Jefferson, AR, USA
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Acute Hepatitis and Pancytopenia in Healthy Infant with Adenovirus. Case Rep Pediatr 2016; 2016:8648190. [PMID: 27340581 PMCID: PMC4908240 DOI: 10.1155/2016/8648190] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 05/10/2016] [Indexed: 01/01/2023] Open
Abstract
Adenoviruses are a common cause of respiratory infection, pharyngitis, and conjunctivitis in infants and young children. They are known to cause hepatitis and liver failure in immunocompromised patients; they are a rare cause of hepatitis in immunocompetent patients and have been known to cause fulminant hepatic failure. We present a 23-month-old immunocompetent infant who presented with acute noncholestatic hepatitis, hypoalbuminemia, generalized anasarca, and pancytopenia secondary to adenovirus infection.
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Serranti D, Montagnani C, Indolfi G, Chiappini E, Galli L, de Martino M. Antibiotic induced liver injury: what about children? J Chemother 2014; 25:255-72. [PMID: 24070133 DOI: 10.1179/1973947813y.0000000090] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Antimicrobial agents are important causes of drug-induced liver injury. They are responsible for about 45% of cases of drug hepatotoxicity. Hepatic damage mechanisms are intrinsic or idiosyncratic. Usually, antibiotics are responsible for idiosyncratic toxicity. This review summarizes the rate of incidence and clinical features of hepatotoxicity due to antibiotics and chemotherapics, with particular attention to data regarding paediatric population. Liver injury features have been systematically evaluated for the most commonly administered antibiotics and chemotherapics in adults, even though there is little information about other widely used compounds, as cephalosporine or clarithromycin, and about antibiotics active against multi-resistant bacteria, as carbapenems, vancomycin, clindamycin, and linezolid. By contrast, there is an abundance of case reports in paediatrics, but very few structured studies have been carried out in children. Children are an important class of antibiotic users, with specific metabolic characteristics, so more studies on them should be carried out.
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Abdulhamid I, Lehr VT. Hepatotoxicity induced by trimethoprim-sulfamethoxazole in a child with cystic fibrosis. J Pediatr Pharmacol Ther 2014; 19:56-9. [PMID: 24782693 DOI: 10.5863/1551-6776-19.1.56] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Patients with cystic fibrosis (CF) have chronic and progressive lung infections with various bacterial organisms that require treatment with oral and intravenous antibiotics on a regular basis. Trimethoprim-sulfamethoxazole (TMP-SMX) is one of the medications used to treat acute pulmonary infectious exacerbations in patients with CF. Hepatic toxicity secondary to TMP-SMX was previously described in normal subjects but has not been reported in children with CF. Here we describe a 14-year-old female child with CF who was given oral TMP-SMX for an acute pulmonary infectious exacerbation. She developed a rash, severe constitutional symptoms, and significant elevation of liver enzyme concentrations secondary to immunity-mediated reaction to TMP-SMX. Discontinuation of TMP-SMX and supportive treatment led to resolution of her symptoms and normalization of liver enzyme concentrations.
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Affiliation(s)
- Ibrahim Abdulhamid
- Pediatric Pulmonary Division, The Carman and Ann Adams Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, Detroit, Michigan
| | - Victoria Tutag Lehr
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan
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McCaughan JA, Courtney AE. Pneumocystis jiroveci pneumonia in renal transplantation: time to review our practice? Nephrol Dial Transplant 2011; 27:13-5. [DOI: 10.1093/ndt/gfr444] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Arai M, Imazeki F, Yonemitsu Y, Kanda T, Fujiwara K, Fukai K, Watanabe A, Sato T, Oda S, Yokosuka O. Opportunistic infection in the patients with acute liver failure: a report of three cases with one fatality. Clin J Gastroenterol 2009; 2:420-424. [PMID: 26192799 DOI: 10.1007/s12328-009-0108-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Accepted: 08/25/2009] [Indexed: 12/19/2022]
Abstract
We report three cases of severe opportunistic infection in patients with acute liver failure (ALF). These cases included a 56-year-old man infected with Cryptococcus neoformans, cytomegarovirus (CMV), Candida albicans and Aspergillus fumigates, as well as a 62-year-old man and a 54-year-old woman infected with pneumocystis pneumonia, CMV and Aspergillus fumigatus. One patient died as a result of the infection rather than liver failure. We stress the importance of opportunistic infection as a consideration in the use of immunosuppressive agents for the treatment of ALF.
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Affiliation(s)
- Makoto Arai
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan.
| | - Fumio Imazeki
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Yutaka Yonemitsu
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Tatsuo Kanda
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Keiichi Fujiwara
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Kenichi Fukai
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
| | - Akira Watanabe
- Division of Control and Treatment of Infectious Disease, Chiba University Hospital, Chiba, Japan
| | - Takeyuki Sato
- Division of Control and Treatment of Infectious Disease, Chiba University Hospital, Chiba, Japan
| | - Shigeto Oda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Osamu Yokosuka
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan
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Abstract
PURPOSE Many children with urological disease require long-term treatment with antibiotics. In many cases the choice of medical instead of surgical management hinges on the implied safety of certain drugs. Recently some groups have advocated subureteral injection procedures to avoid long-term antibiotics for low grade reflux. We present a concise and relevant review on the use and adverse reactions of nitrofurantoin, trimethoprim and sulfamethoxazole in children. MATERIALS AND METHODS We reviewed the literature regarding the safety and toxicity of these drugs. Information regarding absorption, excretion and dosing was also gathered to explain better the mechanisms of toxicity. RESULTS Adverse reactions in children reported in the literature related to nitrofurantoin are gastrointestinal disturbance (4.4/100 person-years at risk), cutaneous reactions (2% to 3%), pulmonary toxicity (9 patients), hepatoxicity (12 patients and 3 deaths), hematological toxicity (12 patients), neurotoxicity and an increased rate of sister chromatid exchanges. Adverse reactions in children related to trimethoprim/sulfamethoxazole are almost exclusively due to the sulfamethoxazole component, including cutaneous reactions (1.4 to 7.4 events per 100 person-years at risk), hematological toxicity (0% to 72% of patients) and hepatotoxicity (5 patients). The majority of adverse reactions were found in children on full dose therapy and not prophylaxis. CONCLUSIONS The use of nitrofurantoin, trimethoprim and sulfamethoxazole is safe in children for long-term prophylactic therapy. The antibiotic safety issue should not be misconstrued as an argument for surgical therapy, whether minimally invasive or not. Adverse reactions exist to these medicines but they are less common than seen in adults, presumably because of the lower dose used for therapy, and the lack of significant comorbidities and drug interactions in children. Serious side effects are extremely rare and most are reversible by discontinuing therapy. The extremely low potential for significant adverse reactions should be discussed with parents.
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Affiliation(s)
- Edward Karpman
- Department of Urology, University of California-Davis-Children's Hospital and School of Medicine, Sacramento, California 95817, USA
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Ilario MJ, Ruiz JE, Axiotis CA. Acute fulminant hepatic failure in a woman treated with phenytoin and trimethoprim-sulfamethoxazole. Arch Pathol Lab Med 2000; 124:1800-3. [PMID: 11100060 DOI: 10.5858/2000-124-1800-afhfia] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Massive hepatic necrosis following exposure to phenytoin and trimethoprim-sulfamethoxazole is a rare occurrence and to the best of our knowledge has not been reported previously. Acute hepatic failure following administration of trimethoprim-sulfamethoxazole has rarely been seen, and only 4 cases have been well documented pathologically. We report a case of acute liver failure in a 60-year-old woman following ingestion of phenytoin and trimethoprim-sulfamethoxazole concomitantly over a 9-day period. Autopsy findings revealed acute fulminant hepatic failure. This case demonstrates the effects of chemical-chemical interactions in the potentiation of hepatotoxicity of single agents and specifically illustrates the need for discontinuing trimethoprim-sulfamethoxazole in the presence of early liver injury.
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Affiliation(s)
- M J Ilario
- Department of Pathology, State University of New York Health Science Center at Brooklyn, 11203, USA
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Abstract
OBJECTIVE To review the literature on the recent available evidence of antibiotic-associated acute liver injury. DATA SOURCES All published articles from January 1990 to July 1995 were extracted from the monthly updated HEPATOX database. Additional articles were found using MEDLINE, EMBASE, and PASCAL searches. Hepatic injuries associated with antituberculous, antimycotic, antiviral, antiprotozoal, and antiseptic compounds were excluded form this review. STUDY SELECTION As the amount of literature was large, only case reports, series and epidemiologic data were used. Results from clinical trials were reviewed only when other information was available. DATA EXTRACTION Original articles were reviewed to select relevant material. Information regarding the clinical description, histologic features, severity, outcome, and possible risk factors was extracted. Data on incidence were provided by epidemiologic studies or spontaneous reporting to regulatory agencies. DATA SYNTHESIS Antibiotic-associated acute injury is rare, with an incidence not exceeding 1 case 10,000 users for most drugs. Among beta-lactams, amoxicillin/clavulanic acid and penicillinase-resistant penicillins are associated with predominant and sometimes protracted cholestasis. The hepatotoxic potential of all available erythromycin salts is confirmed, and recent evidence suggests that roxithromycin could be added to the list of antibiotic-induced liver injury. Among fluoroquinolones, only ciprofloxacin has been associated with serious hepatitis. Trimethoprim/sulfamethoxazole-induced hepatitis often reported, but trimethoprim alone also appears as a possible cause of acute liver injury. Finally, acute bile duct injuries and ductopenia have been described with several antibiotics. CONCLUSIONS The most important recent information is the possibility of protracted liver cholestasis with bile duct injuries induced by several antibiotics, particularly penicillinase-resistant penicillins, and the identification of new potentially hepatotoxic antibiotics, namely, roxithromycin, ciprofloxacin, and trimethoprim.
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Affiliation(s)
- T Vial
- Service de Pharmaco-Toxicovigilance et Centre Anti-Poisons, Pavillon N, Hôpital Edouard Herriot, Lyon, France
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