Tetracycline-induced fatty liver in nonpregnant patients. A report of six cases

A pharmacovigilance study of the association between tetracyclines and hepatotoxicity based on Food and Drug Administration adverse event reporting system data

Background While tetracycline antibiotics are commonly prescribed in practice, the risk of drug-induced liver injury (DILI) remains controversial. Aim To evaluate the association of DILI with tetracycline antibiotics. Method All DILI cases of tetracycline antibiotics as primary suspected drugs were extracted from the US Food and Drug Administration adverse event reporting system (FAERS). The outcomes included severe DILI, hepatocellular injury, cholestatic injury, and liver failure. Disproportionality analyses were conducted by estimating the reporting odds ratio (ROR) and the information component (IC). Results A total of 1,435 liver injury cases associated with tetracycline antibiotics were identified. The DILI signal was detected in tigecycline, minocycline, and doxycycline. The RORs and the 95% confidence intervals (95% CI) of tigecycline, minocycline, and doxycycline were (ROR 5.85, 95% CI 4.96-6.91), (ROR 6.4, 95% CI 5.76-7.11), and (ROR 2.07, 95% CI 1.86-2.31), respectively. Compared to minocycline (ROR 5.5, 95% CI 4.94-6.12; IC 2.35, 95% CI 1.98-2.68) and doxycycline (ROR 1.91, 95% CI 1.71-2.12; IC 0.91, 95% CI 0.55-1.26), tigecycline showed a stronger association with hepatocellular injury (ROR 7.11, 95% CI 6.13-8.23; IC 2.68, 95% CI 2.16-3.13). Tigecycline also showed a stronger association with cholestatic injury (ROR 12.16, 95% CI 10.13-14.61; IC 3.51, 95% CI 2.79-4) than minocycline (ROR 3.23, 95% CI 2.59-4.04; IC 1.67, 95% CI 0.9-2.37) or doxycycline (ROR 2.86, 95% CI 2.47-3.31; IC 1.5, 95% CI 1-1.97). Tigecycline (ROR 6.56, 95% CI 4.57-9.41; IC 2.69, 95% CI 1.28-3.64) and minocycline (ROR 4.22, 95% CI 3.14-5.66; IC 2.06, 95% CI 1-2.93) showed a significant association with liver failure. Conclusion The data mining of FAERS suggested an association between DILI and tigecycline, minocycline, and doxycycline.

The histopathological evaluation of drug-induced liver injury

Drug-induced liver injury (DILI) presents unique challenges to the pathologist. It is not only an uncommon reason for liver biopsy, but the pathology of DILI is spread across the entire spectrum of hepatic injury patterns. It is important for the pathologist to suspect DILI when the histological changes are unusual or out of synchronicity with the patient's history. A systematic evaluation approach will yield the most information. It begins with the characterization of the general pattern of injury which, for most cases, will be found in a handful of necroinflammatory and cholestatic patterns. A careful assessment of the severity of injury across the various anatomic compartments will provide information on the probable natural history of the injury. Correlation of liver injury with the patient's medication history and clinical findings will help to narrow the differential diagnosis, particularly when it is recognized that most drugs have a limited range of histological findings and vary in their propensity to cause injury. This review provides an overview of the assessment of the liver biopsy and its use to confirm or exclude particular drugs as contributing to the patient's liver injury.

Strategies, models and biomarkers in experimental non-alcoholic fatty liver disease research

Non-alcoholic fatty liver disease encompasses a spectrum of liver diseases, including simple steatosis, steatohepatitis, liver fibrosis and cirrhosis and hepatocellular carcinoma. Non-alcoholic fatty liver disease is currently the most dominant chronic liver disease in Western countries due to the fact that hepatic steatosis is associated with insulin resistance, type 2 diabetes mellitus, obesity, metabolic syndrome and drug-induced injury. A variety of chemicals, mainly drugs, and diets is known to cause hepatic steatosis in humans and rodents. Experimental non-alcoholic fatty liver disease models rely on the application of a diet or the administration of drugs to laboratory animals or the exposure of hepatic cell lines to these drugs. More recently, genetically modified rodents or zebrafish have been introduced as non-alcoholic fatty liver disease models. Considerable interest now lies in the discovery and development of novel non-invasive biomarkers of non-alcoholic fatty liver disease, with specific focus on hepatic steatosis. Experimental diagnostic biomarkers of non-alcoholic fatty liver disease, such as (epi)genetic parameters and '-omics'-based read-outs are still in their infancy, but show great promise. In this paper, the array of tools and models for the study of liver steatosis is discussed. Furthermore, the current state-of-art regarding experimental biomarkers such as epigenetic, genetic, transcriptomic, proteomic and metabonomic biomarkers will be reviewed.

Antibiotic induced liver injury: what about children?

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.

Hepatotoxicity of antibiotics: a review and update for the clinician

Collectively, the various classes of antibiotics are a leading cause of drug-induced liver injury (DILI). However, acute antibiotic-associated DILI can be difficult to diagnose, as the course of therapy is usually brief, and other confounding factors are often present. In addition to the broad clinicopathologic spectrum of hepatotoxicity associated with the antimicrobials, the underlying infectious disease being treated may itself be associated with hepatic dysfunction and jaundice. This review provides summarized information on several classes of antimicrobial agents, highlighting new agents causing DILI and updating information on older agents.

Hepatotoxicity of antibacterials: Pathomechanisms and clinical

Drug-induced hepatotoxicity is a frequent cause of liver disease and acute liver failure, particularly in patients treated with multiple drugs. Several antibacterial drugs have the potential to cause severe liver injury and failure. This article aims to increase the awareness and understanding of drug induced liver injury (DILI) due to antibacterial drugs. It reviews the pattern of antibacterial DILI and provides details on molecular mechanisms and toxicogenomics, as well as clinical data based on epidemiology studies. Certain antibacterial drugs are more frequently linked to hepatotoxicity than others. Therefore, the hepatotoxic potential of tetracyclines,sulfonamides, tuberculostatic agents, macrolides, quinolones,and beta-lactams are discussed in more detail. Efforts to improve the early detection of DILI and the acquisition of high-quality epidemiological data are pivotal for increased patient safety.

Hepatotoxicity of antibiotics and antifungals

Hepatotoxicity associated with any antibiotic is rare. With the wide-spread use of antimicrobial agents, however, hepatic injury is not an infrequent occurrence. Penicillins remain a widely used class of antimicrobials with a well defined record of low hepatotoxicity. The combination of clavulanate with amoxicillin may be associated with the greatest risk for liver injury from any antimicrobial agent. Significant hepatotoxicity also may occur with sulfamethoxazole/ trimethoprim and combination regimens used to treat tuberculosis. An autoimmune-like hepatitis may result from minocycline or nitrofurantoin exposure and most often resolves with cessation of therapy. Treatment with high doses of tetracycline and oxacillin may be associated with severe hepatotoxicity. Early suspicion of hepatocellular injury in the setting of antimicrobial exposure should prompt cessation of therapy and avoidance of rechallenge.

Minocycline-induced autoimmune syndromes: an overview

OBJECTIVE

To increase awareness of minocycline-induced autoimmune syndromes.

METHODS

Review of relevant publications from the American and European literature.

RESULTS

Four minocycline-induced syndromes have been described in 82 patients: serum sickness, drug-induced lupus, autoimmune hepatitis, and vasculitis. Aside from sporadic cases of serum sickness, all other syndromes occurred in patients treated for acne. Drug-induced lupus and hepatitis were by far the most common events (66 cases). Except for serum sickness, which presented shortly (mean, 16 days) after minocycline, the autoimmune syndromes manifested after protracted use (mean, 25.3 months). As expected, the patients with acne were young (mean, 19.7 years). The most frequent symptoms were arthralgia, followed by arthritis, fever, and rash (73, 45, 38, and 29 patients, respectively). Serologically, antinuclear antibodies were the most common finding (63 positive of 68 tests); perinuclear anti-neutrophilic cytoplasmic antibodies (pANCA), when assayed, were similarly frequent (20 of 24 tests). Surprisingly, anti-histone antibodies were uncommon, even among patients with drug-induced lupus (4 of 31 tests). The clinical and serological features of the separate syndromes may overlap. The diagnostic value of pANCA, as well as its possible role in minocycline-induced autoimmunity, are discussed.

CONCLUSIONS

Minocycline has the potential to evoke a variety of clinical and serological autoimmune expressions. The number of published reports may underestimate the frequency of this condition, which should be suspected and investigated in young patients with autoimmune manifestations.

Liver reactions to oral low-dose tetracyclines

BACKGROUND

We report on a case of severe liver reaction associated with doxycycline in a previously healthy subject. Furthermore, we estimate the incidence of oral low-dose tetracycline-related liver reactions in relation to sales figures in Sweden and study the clinical and biochemical features of low-dose tetracycline-associated liver injury, on the basis of reports to SADRAC (Swedish Adverse Drug Reactions Advisory Committee) and on the reports in the literature.

METHODS

All liver reactions reported to SADRAC from 1965 to 1995 were surveyed, and articles on liver reactions resulting from tetracycline published during the period 1966-95 were reviewed.

RESULTS

During this 30-year period, 23 liver reactions with a suspected casual relationship to oral, low-dose tetracycline derivatives were reported to SADRAC. A causal relationship was considered likely in 3 and possible in 8 cases, giving an incidence of roughly 1 in 18 million DDD (defined daily doses). No deaths were observed from these liver reactions, and liver enzyme activities normalized in all cases without any serious clinical consequences. A total of three cases of reported tetracycline liver damage were found in the literature. Of these, two were classified as having a likely relationship, and in one a causal relationship was not determinable because of other concomitant drug administration. The liver injury was designated as cholestatic, hepatocellular, and mixed, with similar frequencies.

CONCLUSIONS

Low-dose, oral tetracyclines constitute a likely cause of acute liver damage with a variable biochemical profile. Such reactions are probably very rare.

Acute and reversible fatty metamorphosis of cultured rat hepatocytes

Rat hepatocyte cell line M6, B347 and J525, among which only M6 is slightly deviated from diploidy, showed marked microvesicular fatty metamorphosis in response to treatment with Tweens at concentrations of 0.05-0.025% in Eagle's minimum essential medium (MEM). Within 24 h treated cells became fatty at 100% in frequency and filled with small lipid droplets, as revealed by fat staining or at the ultrastructural level. Fatty hepatocytes, however, took again non-fatty morphology 72 h after withdrawal of Tweens from the culture medium. Growth of the cell exhibited mild retardation at the early phase of the treatment but almost similar cell density to that of control cells was achieved 24 h after the treatment. Other detergents without fatty-acid moiety, including NP-40, triton X-100, sodium deoxycholic acid and sodium cholic acid, were ineffective to induce fatty change. Oleate, a fatty-acid moiety of Tween 80 or 85, and linolate caused reversible fatty metamorphosis of the cell lines at concentrations of 1.9 x 10(4) mol/L or more and 3.8 x 10(4) mol/L or more, respectively. Ethanol induced mild steatosis of the cell lines and enhanced fatty change by linolate. Hepatic fatty acid-binding protein was not detected in the cell lines before or after the induction of fatty change. These results indicate that fatty acid itself is directly incorporated in cultured rat hepatocytes and expelled 3 days later without apparent cell degeneration.

Antibacterial-induced hepatotoxicity. Incidence, prevention and management

Hepatotoxic reactions to antibacterials are rare, occurring with an estimated frequency of between 1 and 10 per 100,000 drug prescriptions for most antibacterials. Although many antibacterial-induced hepatotoxic reactions have a characteristic clinical and biochemical pattern e.g. cholestatic hepatitis (flucloxacillin) or fatty liver (tetracycline), many can also present with a variety of clinicopathological patterns e.g. nitrofurantoin is associated with the development of acute hepatitis, granulomatous hepatitis and chronic active hepatitis. Almost all reactions are idiosyncratic, with no diagnostic laboratory tests to aid the diagnosis. Early diagnosis is essential and requires a vigilant physician to elicit a detailed drug history. Although the outcome is usually good when the offending antibacterial is withdrawn, morbidity may persist for years and fatalities have occurred, particularly when there is a delay in recognising the hepatotoxic antibacterial. There is no specific treatment for antibacterial-induced hepatotoxicity other than withdrawing the implicated drug. For severe disease, however, liver transplantation should be considered.

Drug-induced pancreatitis

Few data exist about the incidence of drug-induced pancreatitis in the general population. 20 cases of drug-related pancreatitis were reported in Switzerland over a period of 12 years. The proportion of cases of pancreatitis caused by drugs is estimated to be around 2% in the general population, with much higher proportions in specific subpopulations, such as children and patients who are HIV positive. The literature about drug-induced pancreatitis consists mainly of anecdotal case reports. Clear evidence of a definite association with pancreatitis, by means of rechallenge tests, or consistent case reports, supported by animal experiments or data on the incidence of acute pancreatitis in drug trials exists for didanosine, valproic acid (sodium valproate), aminosalicylates, estrogen, calcium, anticholinesterases and sodium stibogluconate. An association with drug-induced pancreatitis is likely but not definitely proven for thiazide diuretics, pentamidine, ACE inhibitors, asparaginase, vinca alkaloids, some nonsteroidal anti-inflammatory drugs and clozapine. Pancreatitis is possibly caused by azathioprine, furosemide (frusemide), tetracycline, metronidazole, isoniazid, rifampicin (rifampin), sulphonamides, cyclosporin and some antineoplastic drugs. Many drugs have been reported to be associated with acute pancreatitis. However, lack of rechallenge evidence, consistent statistical data, or evidence from experimental studies on a possible mechanism prohibit definitive conclusions about most of them. The high incidence of concurrent illnesses known to induce acute pancreatitis, makes a trigger role or co-factor role for the drug seem most likely.

Review article: drug-induced pancreatitis

Drugs are a relatively uncommon cause of pancreatitis in adult patients, but should be considered when other reasonable causes of pancreatitis are not present. A wide variety of drugs have been reported to cause pancreatitis. Drug-induced pancreatitis is almost always acute and may be mild to fatal in severity. Definite proof that a drug causes pancreatitis requires that pancreatitis develops during treatment with the drug, that other likely causes of pancreatitis are not present, that pancreatitis resolves upon discontinuing the drug, and that pancreatitis usually recurs upon readministration of the drug. For ethical reasons, rechallenge with the suspect drug can be done only if the drug is necessary to treat a serious condition; thus this highly convincing piece of evidence relating the drug to pancreatitis may not be available. Information about drug-related pancreatitis is often not readily available, particularly for newer drugs. Clinicians should consider obtaining information directly from regulatory agencies and manufacturers as well as the literature.

Minocycline induced autoimmune hepatitis and systemic lupus erythematosus-like syndrome

Monocycline is the most widely prescribed systemic antibiotic for acne largely because it needs to be given only once or twice a day and seems not to induce resistance. Up to April 1994 11 cases of minocycline induced systemic lupus erythematosus and 16 cases of hepatitis had been reported to the Committee on Safety of Medicines. An analysis of these cases together with seven other cases shows the severity of some of these reactions. Two patients died while taking the drug for acne and a further patient needed a liver transplant. Acne itself can induce arthritis and is often seen in association with autoimmine liver disease, but the clinical and biochemical resolution seen after withdrawal of the drug, despite deterioration of the acne, suggests a drug reaction. In five cases re-exposure led to recurrence. Because reactions may be severe early recognition is important to aid recovery and also to avoid invasive investigations and treatments such as corticosteroids and immunosuppresants. Safer alternatives should be considered for treating acne.

Inhibition of mitochondrial beta-oxidation as a mechanism of hepatotoxicity

Severe and prolonged impairment of mitochondrial beta-oxidation leads to microvesicular steatosis, and, in severe forms, to liver failure, coma and death. Impairment of mitochondrial beta-oxidation may be either genetic or acquired, and different causes may add their effects to inhibit beta-oxidation severely and trigger the syndrome. Drugs and some endogenous compounds can sequester coenzyme A and/or inhibit mitochondrial beta-oxidation enzymes (aspirin, valproic acid, tetracyclines, several 2-arylpropionate anti-inflammatory drugs, amineptine and tianeptine); they may inhibit both mitochondrial beta-oxidation and oxidative phosphorylation (endogenous bile acids, amiodarone, perhexiline and diethylaminoethoxyhexestrol), or they may impair mitochondrial DNA transcription (interferon-alpha), or decrease mitochondrial DNA replication (dideoxynucleoside analogues), while other compounds (ethanol, female sex hormones) act through a combination of different mechanisms. Any investigational molecule should be screened for such effects.

Late-onset drug fever associated with minocycline

A patient presenting with a pyrexial illness and transiently deranged liver function tests is described. He had been taking minocycline for 12 months. The causal association with this drug was demonstrated by withholding and then rechallenging with minocycline. This report documents drug fever as an adverse reaction to minocycline, and its late onset is of added interest.

Liver disease in pregnancy

The diseases which affect the liver in pregnancy can be subdivided into those which occur simultaneously with gestation and those which occur in the context of and exclusively during pregnancy. This review deals with the latter group and describes the histopathological features of acute fatty liver of pregnancy and liver disease in toxaemia of pregnancy, hyperemesis gravidarum and intrahepatic cholestasis of pregnancy.

The medical and scientific evidence in alleged tubocurarine poisonings. A review of the so-called Dr. X case

The problem of proving the presence or absence of a poison in a buried cadaver is the central theme of this presentation. Certain general questions are posed which may serve to guide those seeking to determine the cause of death in buried cadavers and allegedly due to a poison. Medicolegal and scientific evidence is presented from the court records of five deaths which were alleged homicides due to intravenous tubocurarine. As to the medical evidence: The prosecution claimed absence of adequate medical causes but full congruence with intravenous tubocurarine as the cause of death. The defense claimed and presented its evidence, including history, clinical picture, gross and microscopic pathological findings--for the deaths having occurred from competent natural causes in all but one case. In that one case the cause was undetermined. In two of the four cases evidence was presented for the mechanism of death and why they died at the time that they did. As to the forensic toxicological evidence: The prosecution claimed qualitative identification but with no particular quantitative detection or identification limits of tubocurarine in the remains based on results of combinations of HPLC followed by RIA and of some selected ion direct inlet mass spectrometry. The defense corroborated--along with a quantitative estimate--the presence of a substantial concentration of tubocurarine in the liver specimen of one case. However the chain of custody of this particular specimen was compromised for a period of several days between post-exhumation autopsy and submission to the prosecution toxicologists. With respect to all the other specimens examined by the defense, direct inlet mass spectrometry failed to show ions which are critical for establishing the identity of tubocurarine. The defense also presented results of experiments which showed that the tissues of the cases in question destroyed tubocurarine at such a rate that no reasonably conceivable administered amount could have survived the 10 years of burial of these cases. In each of the five cases exhumation and re-autopsy would have been found to be neither justified nor even indicated had an objective examination of the available record been made and supplemented by a similarly objective review of the literature and the simple stability experiments used by the defense. After an 8-month trial, the jury brought in a not guilty verdict on all counts after less than 2 h of deliberations.

Can tetracycline-induced fatty liver in pregnancy be attributed to choline deficiency?

Pregnant women, especially those in their third trimester, are particularly susceptible to tetracycline-induced fatty liver. Experimental evidence obtained in rats suggest that the precipitous fall in maternal liver choline concentration nearing the end of pregnancy could lead to a severe reduction in the lipotropic activity of the liver. It is hypothesised that the liver in this state will be at much greater risk of developing fatty degeneration, especially if it is exposed to hepatotoxic agents such as tetracycline.

Tetracycline-induced pancreatitis

The assumption that tetracycline HCl can cause acute pancreatitis has been accepted since reports began to appear implicating it as a cause of fatty liver in pregnancy with associated pancreatitis. It is listed as an etiologic factor for acute pancreatitis in reference articles and standard medical textbooks without good documentation of this association in the absence of fatty liver. This report describes a documented case of tetracycline HCl-induced acute pancreatitis without associated overt liver disease.

Drug-induced pancreatitis: a critical review

We critically reviewed the English language literature pertaining to drug-induced pancreatitis and attempted to determine whether the reported association between each drug and pancreatitis was valid. The following drugs seem to cause pancreatitis: azathioprine, thiazides, sulfonamides, furosemide, estrogens, and tetracycline. Less convincing, but suggestive evidence exists for: 1-asparaginase, iatrogenic hypercalcemia, chlorthalidine, corticosteroids, ethacrynic acid, phenformin, and procainamide. Evidence implicating other drugs is either inadequate or contradictory. Little is known about the pathogenesis of drug-induced pancreatitis. Ethanol was not considered in this review.

Severe metabolic acidosis as a complication of intravenous tetracycline therapy

Tetracycline generally is believed to be a safe drug with relatively minor side effects. Serious irreversible renal damage and metabolic acidosis can occur in patients with azotemia. While the exact mechanism is unknown, the commonly reported nephrotoxic and metabolic effects of tetracycline are reviewed and an illustrative case is presented.