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Shionoya K, Kobayashi M, Kako M, Masuda S, Makazu M, Koizumi K. Drug-induced Liver Injury Considered Steroid-resistant and Histologically Diagnosed with Vanishing Bile Duct Syndrome. Intern Med 2024; 63:1719-1723. [PMID: 37952956 DOI: 10.2169/internalmedicine.2427-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023] Open
Abstract
Vanishing bile duct syndrome (VBDS) is characterized by bile duct degeneration and necrosis, which result in bile duct loss and bile stasis. A 70-year-old man had malaise after receiving celecoxib. Laboratory tests revealed elevated hepatobiliary enzymes. His condition worsened without response to medical treatment, and he was transferred to our hospital. A liver biopsy revealed severe bile duct injury and mild cholestasis. He was diagnosed with celecoxib-induced VBDS and underwent bilirubin adsorption therapy. However, his condition continued to deteriorate, and he died. An autopsy showed that liver regeneration was poor, and bile duct loss was exacerbated. The pathological autopsy findings were consistent with VBDS.
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Affiliation(s)
- Kento Shionoya
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Japan
| | - Masahiro Kobayashi
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Japan
| | - Makoto Kako
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Japan
| | - Sakue Masuda
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Japan
| | - Makomo Makazu
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Japan
| | - Kazuya Koizumi
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Japan
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Takaki Y, Murahashi M, Honda K, Hirai K. L-carbocisteine can cause cholestasis with vanishing bile duct syndrome in children: A case report. Medicine (Baltimore) 2022; 101:e31486. [PMID: 36397354 PMCID: PMC9666201 DOI: 10.1097/md.0000000000031486] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
RATIONALE Vanishing bile duct syndrome (VBDS) is the acquired progressive destruction and disappearance of intrahepatic interlobular bile ducts in the absence of underlying liver or biliary tract disease, causing chronic cholestasis. Infections, drugs, toxins, malignant diseases, and certain immunological processes are associated with the development of this syndrome. There have been no reports of children developing VBDS as a consequence of the administration of L-carbocisteine. PATIENT CONCERNS A 9-year-old Japanese girl presented with fever, jaundice, and skin rash. Laboratory investigations revealed elevated levels of serum transaminases, γ-glutamyltransferase, and bilirubin. Histopathological features were consistent with a diagnosis of VBDS. Drug-induced lymphocyte stimulation tests (DLST) were positive for L-carbocisteine. DIAGNOSIS VBDS caused by L-carbocisteine. INTERVENTIONS Ursodeoxycholic acid and discontinuation of L-carbocisteine. OUTCOMES The patient responded to treatment based upon discontinuation of L-carbocisteine and administration of ursodeoxycholic acid. Her transaminase and bilirubin levels were normalized gradually. LESSONS Physicians should be aware of the fact that L-carbocisteine can cause cholestasis with VBDS in children.
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Affiliation(s)
- Yugo Takaki
- Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
- * Correspondence: Yugo Takaki, Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, 2-1-1 Nagamine-Minami, Higashi-ku, Kumamoto 861-8520, Japan (e-mail: )
| | - Makoto Murahashi
- Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Kei Honda
- Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
| | - Katsuki Hirai
- Department of Pediatrics, Japanese Red Cross Kumamoto Hospital, Kumamoto, Japan
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Wasuwanich P, Choudry H, So JM, Lowry S, Karnsakul W. Vanishing bile duct syndrome after drug-induced liver injury. Clin Res Hepatol Gastroenterol 2022; 46:102015. [PMID: 36067952 DOI: 10.1016/j.clinre.2022.102015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 08/23/2022] [Accepted: 09/02/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Vanishing bile duct syndrome (VBDS) is a serious cholestatic liver disease that can be a complication of drug-induced liver injury (DILI). While journals have published case reports of this condition, large studies on a cohort of these patients are lacking. We aimed to compile published case reports and case series of patients with VBDS and DILI to describe the clinical and laboratory characteristics of the disease and identify factors associated with good and poor outcomes. METHODS We included case reports and case series of VBDS secondary only to DILI. We extracted demographic, clinical, laboratory, treatment, and exposure data from each case report and categorized cases by outcome, good versus poor. We defined poor outcomes as cases with severe long-term complications or death. We analyzed risk factors for poor outcomes using logistic regression. RESULTS We identified a total of 59 eligible cases. Of those, 39 (59%) were female, the median age was 36 (IQR:12-58), and 18 (31%) were pediatric cases (≤18 years). The most common offending drug class was antibiotics, especially beta-lactams. Patients with increased total bilirubin (OR=4.69; 95% CI=1.55-15.49; p = 0.008), increased direct bilirubin (OR=6.50; 95% CI=1.34-48.91; p = 0.034), lower liver synthetic activity (OR=0.11; 95% CI=0.02-0.55; p = 0.013), and older age (OR=3.31; 95% CI=1.15-10.04; p = 0.029) were more likely to develop poor outcomes. CONCLUSIONS In patients with VBDS and DILI, antibiotics were the most common offending agents. Higher total and direct bilirubin levels were associated with poor outcomes.
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Affiliation(s)
- Paul Wasuwanich
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Hassan Choudry
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joshua M So
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Sarah Lowry
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wikrom Karnsakul
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Lin WC, Hsieh TS, Chu CY. Case report: Development of vanishing bile duct syndrome in Stevens-Johnson syndrome complicated by hemophagocytic lymphohistiocytosis. Front Med (Lausanne) 2022; 9:975754. [PMID: 36353223 PMCID: PMC9637682 DOI: 10.3389/fmed.2022.975754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/10/2022] [Indexed: 07/25/2023] Open
Abstract
BACKGROUND Vanishing bile duct syndrome is a rare drug-induced disease characterized by cholestasis and ensuing ductopenia. Dermatological manifestations of drug hypersensitivity such as Stevens-Johnson syndrome and toxic epidermal necrolysis may also present in such cases. Hemophagocytic lymphohistiocytosis is a hyperimmune response caused by unchecked stimulation of macrophages, natural killer cells, and cytotoxic T lymphocytes. CASE PRESENTATION We report a severe case who presented with concurrent Stevens-Johnson syndrome and vanishing bile duct syndrome complicated by hemophagocytic lymphohistiocytosis after the ingestion of non-steroidal anti-inflammatory drugs. Despite the fact that improvements in vanishing bile duct syndrome can be assumed when combining the clinical lab data clues, as well as repeated liver biopsies showing recovering ductopenia, the patient developed hypovolemic shock combined with septic shock episodes and died on day 236. CONCLUSION To our knowledge, this is the fifteenth report of vanishing bile duct syndrome associated with Stevens-Johnson disease or toxic epidermal necrolysis. Mortality rate remains high without treatment guidelines established due to the rarity and heterogenicity of the population. Further studies are needed to identify possible risk factors, prognostic indicators, and the standard of care for vanishing bile duct syndrome associated with Stevens-Johnson disease or toxic epidermal necrolysis.
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Affiliation(s)
- Wan-Chen Lin
- Department of Dermatology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Dermatology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Tyng-Shiuan Hsieh
- Department of Dermatology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Dermatology, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chia-Yu Chu
- Department of Dermatology, National Taiwan University Hospital, Taipei, Taiwan
- Department of Dermatology, National Taiwan University College of Medicine, Taipei, Taiwan
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Bessone F, Hernández N, Tanno M, Roma MG. Drug-Induced Vanishing Bile Duct Syndrome: From Pathogenesis to Diagnosis and Therapeutics. Semin Liver Dis 2021; 41:331-348. [PMID: 34130334 DOI: 10.1055/s-0041-1729972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The most concerned issue in the context of drug/herb-induced chronic cholestasis is vanishing bile duct syndrome. The progressive destruction of intrahepatic bile ducts leading to ductopenia is usually not dose dependent, and has a delayed onset that should be suspected when abnormal serum cholestasis enzyme levels persist despite drug withdrawal. Immune-mediated cholangiocyte injury, direct cholangiocyte damage by drugs or their metabolites once in bile, and sustained exposure to toxic bile salts when biliary epithelium protective defenses are impaired are the main mechanisms of cholangiolar damage. Current therapeutic alternatives are scarce and have not shown consistent beneficial effects so far. This review will summarize the current literature on the main diagnostic tools of ductopenia and its histological features, and the differential diagnostic with other ductopenic diseases. In addition, pathomechanisms will be addressed, as well as the connection between them and the supportive and curative strategies for ductopenia management.
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Affiliation(s)
- Fernando Bessone
- Hospital Provincial del Centenario, Facultad de Ciencias Médicas, Servicio de Gastroenterología y Hepatología, Universidad Nacional de Rosario, Rosario, Argentina
| | - Nelia Hernández
- Clínica de Gastroenterología, Hospital de Clínicas y Facultad de Medicina, Universidad de la República (UdelaR), Montevideo, Uruguay
| | - Mario Tanno
- Hospital Provincial del Centenario, Facultad de Ciencias Médicas, Servicio de Gastroenterología y Hepatología, Universidad Nacional de Rosario, Rosario, Argentina
| | - Marcelo G Roma
- Instituto de Fisiología Experimental (CONICET-UNR), Facultad de Ciencias Bioquímicas y Farmacéuticas, Universidad Nacional de Rosario, Rosario, Argentina
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Shen X, Huang Y, Guo H, Peng H, Yao S, Zhou M, Liu H, Lin HC, Zhou P. Oral ibuprofen promoted cholestatic liver disease in very low birth weight infants with patent ductus arteriosus. Clin Res Hepatol Gastroenterol 2021; 45:101495. [PMID: 32723673 DOI: 10.1016/j.clinre.2020.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 06/20/2020] [Accepted: 06/23/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Hemodynamically significant patent ductus arteriosus (hsPDA) in very low birth weight (VLBW) infants is routinely treated in many countries with oral ibuprofen. This study retrospectively assessed whether the risk of cholestatic liver disease (CLD) increased due to oral ibuprofen administration in VLBW infants. METHODS A total of 122 VLBW preterm infants (26∼32 weeks, birth weight<1500g) diagnosed with patent ductus arteriosus (PDA) admitted to our neonatal intensive care unit (NICU) between September 2016 to August 2018 were included. Sixty-four infants were diagnosed with hs-PDA and received ibuprofen treatment. VLBW infants with PDA untreated with ibuprofen served as controls. Soybean oil and fat emulsions were routinely added to parenteral nutrition (PN). Once CLD was diagnosed, the fat emulsions were immediately replaced with multi-oil fat emulsion injections. To assess the independent association of treatment and duration of ibuprofen with CLD and duration of fasting and PN, binary logistic regression or multivariate linear regression analyses were conducted, adjusting for major confounders (birth weight, gestational age, Clinical Risk Index for Babies, and cholestasis-associated risk factors). RESULTS The duration of PN increased due to ibuprofen treatment for 6.559 days (95% CI: 1.769, 11.349; P=0.008), and the risk of prolonged fasting (cutoff>5 days) might have increased due to ibuprofen treatment (OR: 3.043, 95% CI: 0.965, 9.594; P=0.057). Furthermore, CLD was influenced by ibuprofen treatment (OR: 6.730; 95% CI: 1.279, 35.41; P=0.024), early thrombocytopenia 7 days postnatal (OR: 6.996; 95% CI: 1.769, 27.658; P=0.004), and late onset sepsis (OR: 6.976; 95% CI: 1.561, 31.169; P=0.011). Further analysis adjusting for cholestasis-associated risk factors revealed that CLD was influenced by the duration of ibuprofen treatment (OR: 2.864; 95% CI: 1.104, 7.422; P=0.030), Platlets counts 7 days postnatal (OR: 0.971; 95% CI: 0.950, 0.994; P=0.013), and duration of antibiotics (OR: 1.134; 95% CI: 1.002, 1.282; P=0.046). CONCLUSIONS This retrospective study indicated oral ibuprofen duration-dependently increased the risk of CLD in VLBW infants with PDA, and early thrombocytopenia served as the critical risk factor.
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Affiliation(s)
- Xintian Shen
- Department of Pharmacy, Shenzhen Baoan Women's and Children's Hospital, Jinan University, Shenzhen, 518102, China.
| | - Yie Huang
- Department of Hospital Infection Control, Shenzhen Baoan Women's and Children's Hospital, Jinan University, Shenzhen, 518102, China
| | - Huijuan Guo
- Department of Pharmacy, Shenzhen Baoan Women's and Children's Hospital, Jinan University, Shenzhen, 518102, China
| | - Haibo Peng
- Neonatal Intensive Care Unit, Shenzhen Baoan Women's and Children's Hospital, Jinan University, Shenzhen, 518102, China
| | - Shihuan Yao
- Department of Pharmacy, Shenzhen Baoan Women's and Children's Hospital, Jinan University, Shenzhen, 518102, China
| | - Man Zhou
- Department of Pharmacy, Shenzhen Baoan Women's and Children's Hospital, Jinan University, Shenzhen, 518102, China
| | - Hui Liu
- Department of Pharmacy, Shenzhen Baoan Women's and Children's Hospital, Jinan University, Shenzhen, 518102, China
| | - Hung-Chih Lin
- Department of Neonatology, China Medical University Children's Hospital, Taichung, Taiwan; Asia University Hospital, Asia University, Taichung, Taiwan
| | - Ping Zhou
- Department of Hospital Infection Control, Shenzhen Baoan Women's and Children's Hospital, Jinan University, Shenzhen, 518102, China.
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Shanbhag SS, Chodosh J, Fathy C, Goverman J, Mitchell C, Saeed HN. Multidisciplinary care in Stevens-Johnson syndrome. Ther Adv Chronic Dis 2020; 11:2040622319894469. [PMID: 32523661 PMCID: PMC7236394 DOI: 10.1177/2040622319894469] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 11/12/2019] [Indexed: 12/17/2022] Open
Abstract
Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are potentially fatal mucocutaneous diseases that can involve many organ systems. Manifestations of SJS/TEN outside of the skin, eyes, and oral mucosa are not well defined or well recognized, and, therefore, are often not addressed clinically. As supportive care improves and mortality from SJS/TEN decreases, chronic complications in affected organ systems are becoming more prevalent. Recognition of the manifestations of SJS/TEN in the acute phase is critical to optimal care. In this review, we review the organ systems that may be involved in SJS/TEN, provide an overview of their management, and propose a list of items that should be communicated to the patient and family upon discharge. The organ systems discussed include the pulmonary, gastrointestinal/hepatic, oral, otorhinolaryngologic, gynecologic, genitourinary, and renal systems. In addition, the significant psychosocial, nutritional, and pain consequences and management of SJS/TEN are discussed.
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Affiliation(s)
- Swapna S Shanbhag
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - James Chodosh
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Cherie Fathy
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jeremy Goverman
- Department of Surgery, Massachusetts General Hospital, Sumner Redstone Burn Center, Boston, MA, USA
| | - Caroline Mitchell
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
| | - Hajirah N Saeed
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114, USA
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Abstract
Idiopathic adulthood ductopenia (IAD) is a chronic small duct cholestatic biliary disease that is characterized by the loss of interlobular bile ducts. It is diagnosed when there is biochemical evidence of cholestatic liver disease, ductopenia on liver biopsy, and no other identifiable cause of cholestasis. We present a patient with 10 days of progressive abdominal pain, jaundice, and worsening liver function tests who advanced to fulminant liver failure with no apparent underlying cause. He was found to have cirrhosis, with biopsy demonstrative of ductopenia, consistent with idiopathic adulthood ductopenia, which is a rare etiology of cirrhosis but should be considered when the typical workup yields no answer.
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9
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Zoubek ME, Lucena MI, Andrade RJ, Stephens C. Systematic review: ibuprofen-induced liver injury. Aliment Pharmacol Ther 2020; 51:603-611. [PMID: 31984540 DOI: 10.1111/apt.15645] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/16/2019] [Accepted: 01/09/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are a leading cause of drug-induced liver injury (DILI) across the world. Ibuprofen is one of the most commonly used and safest NSAIDs, nevertheless reports on ibuprofen-induced hepatotoxicity are available. AIM To analyse previously published information on ibuprofen-induced liver injury for a better characterisation of its phenotypic expression. METHOD A systematic search was performed and information on ibuprofen-induced liver injury included in case series and case reports, in terms of demographic, clinical, biochemical and outcome data, was analysed. RESULTS Twenty-two idiosyncratic ibuprofen hepatotoxicity cases were identified in the literature, suggesting a very low prevalence of this type of DILI. These patients had a mean age of 31 years and 55% were females. Mean cumulative dose of ibuprofen and time to onset were 30 g and 12 days, respectively. Hepatocellular injury was the most frequently involved liver injury pattern. Six cases developed vanishing bile duct syndrome. Full recovery occurred in 11 patients after a mean time of 14 weeks, whereas five cases evolved to acute liver failure leading to death/liver transplantation. CONCLUSIONS When assessing potential hepatotoxicity cases, physicians should keep in mind that ibuprofen has been associated with hepatotoxicity in the literature. Ibuprofen-associated DILI presents commonly as hepatocellular damage after a short latency period. Published reports on ibuprofen hepatotoxicity leading to liver failure resulting in liver transplantation or death are available. However, due to the apparent low absolute risk of ibuprofen-induced liver complications, ibuprofen can be regarded as an efficacious and safe NSAID.
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Affiliation(s)
- Miguel E Zoubek
- Unidad de Gestión Clínica de Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga, Universidad de Málaga, Málaga, Spain.,Department of Pharmacology and Toxicology, Maastricht University Medical Center, Maastricht, The Netherlands.,School for Nutrition and Translational Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - María Isabel Lucena
- Unidad de Gestión Clínica de Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga, Universidad de Málaga, Málaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Platform for Clinical Research and Clinical Trials IBIMA, SCReN (Spanish Clinical Research Network), Universidad de Málaga, Málaga, Spain
| | - Raúl J Andrade
- Unidad de Gestión Clínica de Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga, Universidad de Málaga, Málaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Camilla Stephens
- Unidad de Gestión Clínica de Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga, Universidad de Málaga, Málaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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Zoubek ME, Woitok MM, Sydor S, Nelson LJ, Bechmann LP, Lucena MI, Andrade RJ, Bast A, Koek GH, Trautwein C, Cubero FJ. Protective role of c-Jun N-terminal kinase-2 (JNK2) in ibuprofen-induced acute liver injury. J Pathol 2018; 247:110-122. [PMID: 30264435 DOI: 10.1002/path.5174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/26/2018] [Accepted: 09/20/2018] [Indexed: 12/24/2022]
Abstract
Ibuprofen is a worldwide used non-steroidal anti-inflammatory drug which may cause acute liver injury (ALI) requiring liver transplantation. We aimed to unveil the molecular pathways involved in triggering ibuprofen-induced ALI, which, at present, remain elusive. First, we investigated activation of essential pathways in human liver sections of ibuprofen-induced ALI. Next, we assessed the cytotoxicity of ibuprofen in vitro and developed a novel murine model of ibuprofen intoxication. To assess the role of JNK, we used animals carrying constitutive deletion of c-Jun N-terminal kinase 1 (Jnk1-/- ) or Jnk2 (Jnk2-/- ) expression and included investigations using animals with hepatocyte-specific Jnk deletion either genetically (Jnk1Δhepa ) or by siRNA (siJnk2Δhepa ). We found in human and murine samples of ibuprofen-induced acute liver failure that JNK phosphorylation was increased in the cytoplasm of hepatocytes and other non-liver parenchymal cells (non-LPCs) compared with healthy tissue. In mice, ibuprofen intoxication resulted in a significantly stronger degree of liver injury compared with vehicle-treated controls as evidenced by serum transaminases, and hepatic histopathology. Next, we investigated molecular pathways. PKCα, AKT, JNK and RIPK1 were significantly increased 8 h after ibuprofen intoxication. Constitutive Jnk1-/- and Jnk2-/- deficient mice exhibited increased liver dysfunction compared to wild-type (WT) animals. Furthermore, siJnk2Δhepa animals showed a dramatic increase in biochemical markers of liver function, which correlated with significantly higher serum liver enzymes and worsened liver histology, and MAPK activation compared to Jnk1Δhepa or WT animals. In our study, cytoplasmic JNK activation in hepatocytes and other non-LPCs is a hallmark of human and murine ibuprofen-induced ALI. Functional in vivo analysis demonstrated a protective role of hepatocyte-specific Jnk2 during ibuprofen ALI. Copyright © 2018 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Miguel E Zoubek
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
- Department of Toxicology, Faculty of Health, Medicine and Life Sciences, School for Nutrition, Toxicology and Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Marius M Woitok
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Svenja Sydor
- Department of Gastroenterology and Hepatology, University Hospital Duisburg-Essen, Essen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
| | - Leonard J Nelson
- Institute for Bioengineering (IBioE), Human Tissue Engineering, Faraday Building, The University of Edinburgh, Edinburgh, UK
| | - Lars P Bechmann
- Department of Gastroenterology and Hepatology, University Hospital Duisburg-Essen, Essen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
| | - Maria I Lucena
- Unidad de Gestión Clínica de Enfermedades Digestivas, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain
| | - Raul J Andrade
- Unidad de Gestión Clínica de Enfermedades Digestivas, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain
| | - Aalt Bast
- Department of Toxicology, Faculty of Health, Medicine and Life Sciences, School for Nutrition, Toxicology and Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
| | - Ger H Koek
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center and School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands
- Department of Visceral Surgery and Transplantation, University Hospital RWTH Aachen, Aachen, Germany
| | - Christian Trautwein
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Francisco J Cubero
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
- Department of Immunology, Ophthalmology and ORL, Complutense University School of Medicine, Madrid, Spain
- 12 de Octubre Health Research Institute (imas12), Madrid, Spain
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11
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Xie W, Wang Q, Gao Y, Pan CQ. Vanishing bile duct syndrome with hyperlipidemia after ibuprofen therapy in an adult patient: a case report. BMC Gastroenterol 2018; 18:142. [PMID: 30268094 PMCID: PMC6162916 DOI: 10.1186/s12876-018-0869-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 09/06/2018] [Indexed: 12/15/2022] Open
Abstract
Background Non-steroidal anti-inflammatory drugs (NSAIDs) are frequently prescribed drugs and can cause drug-induced liver injury. Although patients with drug-induced liver injury from NSAIDs often recover spontaneously, 3% of them required hospitalization and those with persistent cholestasis present a diagnostic challenge. Recently, a few cases of children with persistent jaundice reported have been linked to the vanishing bile duct syndrome. However, data on adult patients is limited. Case presentation We report herein a case of an adult patient who had persistent cholestasis with hyperlipidemia from the VBDS after ibuprofen use. We described a female patient with severe jaundice after taking ibuprofen, although she had no history of liver disease before. The drug-induced liver injury from ibuprofen was identified by clinical features and liver biopsy, which included the Roussel Uclaf Causality Assessment Method scores of 6 and pathological features of cholestasis with stage four drug-induced injury as well as loss of bile duct structures. The clinical course was featuring with persistently high levels of bilirubin associated with hyperlipidemia over the period of one month, although the laboratory abnormalities were slightly improved spontaneously after the cessation of ibuprofen. Her autoantibodies markers including AMA-M2 ASMA, RO-52, LKM, SLA, and anti-glycoprotein-210 were negative. The second liver biopsy was performed on day 213 due to persistent hyperbilirubinemia. Pathological findings were consistent with the diagnosis of vanishing bile duct syndrome. Conclusions A rare case of ibuprofen-associated vanishing bile duct syndrome in an adult female patient is presented. Clinicians need to be aware of vanishing bile duct syndrome as a serious consequence of ibuprofen use in adult patients, although ibuprofen is considered to be among the safest NSAIDs.
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Affiliation(s)
- Wen Xie
- Center of Liver Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Qi Wang
- Center of Liver Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yuanjiao Gao
- Center of Liver Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Calvin Q Pan
- Division of Gastroenterology and Hepatology, Department of Medicine, NYU Langone Health, New York University School of Medicine, 132-21 41Ave, Flushing, New York, 11355, USA.
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12
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Abstract
Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are considered a delayed-type hypersensitivity reaction to drugs. They represent true medical emergencies and an early recognition and appropriate management is decisive for the survival. SJS/TEN manifest with an "influenza-like" prodromal phase (malaise, fever), followed by painful cutaneous and mucous membrane (ocular, oral, and genital) lesions, and other systemic symptoms. The difference between SJS, SJS/TEN overlap, and TEN is defined by the degree of skin detachment: SJS is defined as skin involvement of < 10%, TEN is defined as skin involvement of > 30%, and SJS/TEN overlap as 10-30% skin involvement. The diagnosis of different degrees of epidermal necrolysis is based on the clinical assessment in conjunction with the corresponding histopathology. The mortality rates for SJS and TEN have decreased in the last decades. Today, the severity-of-illness score for toxic epidermal necrolysis (SCORTEN) is available for SJS/TEN severity assessment. Drugs with a high risk of causing SJS/TEN are anti-infective sulfonamides, anti-epileptic drugs, non-steroidal anti-inflammatory drugs of the oxicam type, allopurinol, nevirapine, and chlormezanone. Besides conventional drugs, herbal remedies and new biologicals should be considered as causative agents. The increased risk of hypersensitivity reactions to certain drugs may be linked to specific HLA antigens. Our understanding of the pathogenesis of SJS/TEN has improved: drug-specific T cell-mediated cytotoxicity, genetic linkage with HLA- and non-HLA-genes, TCR restriction, and cytotoxicity mechanisms were clarified. However, many factors contributing to epidermal necrolysis still have to be identified, especially in virus-induced and autoimmune forms of epidermal necrolysis not related to drugs. In SJS/TEN, the most common complications are ocular, cutaneous, or renal. Nasopharyngeal, esophageal, and genital mucosal involvement with blisters, erosions as well as secondary development of strictures also play a role. However, in the acute phase, septicemia is a leading cause of morbidity and fatality. Pulmonary and hepatic involvement is frequent. The acute management of SJS/TEN requires a multidisciplinary approach. Immediate withdrawal of potentially causative drugs is mandatory. Prompt referral to an appropriate medical center for specific supportive treatment is of utmost importance. The most frequently used treatments for SJS/TEN are systemic corticosteroids, immunoglobulins, and cyclosporine A.
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14
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Chong I, Chao A. Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis and Treatment With a Biologic: A Case Report. Perm J 2018; 21:16-060. [PMID: 28488978 DOI: 10.7812/tpp/16-060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION One of the most dangerous dermatologic emergencies is Stevens-Johnson Syndrome (SJS)/toxic epidermal necrolysis (TEN). Although a rare disease, it can often lead to significant mortality. CASE PRESENTATION In this case report, we present a 77-year-old man who developed a sloughing rash that was secondary to a nonsteroidal anti-inflammatory drug. In addition to the recommended supportive care, the patient was treated with etanercept, a new, less commonly used intervention. DISCUSSION We provide a brief review of SJS/TEN. Nonsteroidal anti-inflammatory drugs are a rare cause of SJS/TEN, and additionally, the use of biologics is a novel treatment modality for SJS/TEN.
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Affiliation(s)
- Ian Chong
- Attending Physician in Emergency Medicine at the Zion Medical Center in San Diego, CA.
| | - Alice Chao
- Attending Physician in Emergency Medicine at the Santa Clara Medical Center in CA.
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15
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Sundaram V, Björnsson ES. Drug-induced cholestasis. Hepatol Commun 2017; 1:726-735. [PMID: 29404489 PMCID: PMC5678916 DOI: 10.1002/hep4.1088] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 06/25/2017] [Accepted: 08/07/2017] [Indexed: 12/14/2022] Open
Abstract
Cholestatic drug-induced liver injury (DILI) can be a diagnostic challenge due to a large differential diagnosis, variability in clinical presentation, and lack of serologic biomarkers associated with this condition. The clinical presentation of drug-induced cholestasis includes bland cholestasis, cholestatic hepatitis, secondary sclerosing cholangitis, and vanishing bile duct syndrome. The associate mortality of cholestatic DILI can be as high as 10%, and thus prompt recognition and removal of the offending agent is of critical importance. Several risk factors have been identified for drug-induced cholestasis, including older age, genetic determinants, and properties of certain medications. Antibiotics, particularly amoxicillin/clavulanate, remain the predominant cause of cholestatic DILI, although a variety of other medications associated with this condition have been identified. In this review, we summarize the presentation, clinical approach, risk factors, implicated medications, and management of drug-induced cholestatic liver injury. (Hepatology Communications 2017;1:726-735).
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Affiliation(s)
- Vinay Sundaram
- Department of Medicine and Comprehensive Transplant CenterCedars‐Sinai Medical CenterLos AngelesCA
| | - Einar S. Björnsson
- Section of Gastroenterology and Hepatology, Department of Internal MedicineNational University Hospital of IcelandReykjavíkIceland
- Faculty of Medicine and School of EducationUniversity of IcelandReykjavíkIceland
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16
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Lee H, Walsh S, Creamer D. Long-term complications of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN): the spectrum of chronic problems in patients who survive an episode of SJS/TEN necessitates multidisciplinary follow-up. Br J Dermatol 2017; 177:924-935. [DOI: 10.1111/bjd.15360] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2017] [Indexed: 12/14/2022]
Affiliation(s)
- H.Y. Lee
- Department of Dermatology; Singapore General Hospital; Singapore
| | - S.A. Walsh
- Department of Dermatology; King's College Hospital; London U.K
| | - D. Creamer
- Department of Dermatology; King's College Hospital; London U.K
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17
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Momen S, Dangiosse C, Wedgeworth E, Walsh S, Creamer D. A case of toxic epidermal necrolysis and vanishing bile duct syndrome, requiring liver transplantation. J Eur Acad Dermatol Venereol 2017; 31:e450-e452. [DOI: 10.1111/jdv.14290] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- S. Momen
- Department of Dermatology; King's College Hospital; SE5 9RS London UK
| | - C. Dangiosse
- Department of Hepatology; King's College Hospital; SE5 9RS London UK
| | - E. Wedgeworth
- St John's Institute of Dermatology; Guy's and St Thomas Foundation Trust; SE1 9RT London UK
| | - S. Walsh
- Department of Dermatology; King's College Hospital; SE5 9RS London UK
| | - D. Creamer
- Department of Dermatology; King's College Hospital; SE5 9RS London UK
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18
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Basturk A, Artan R, Yılmaz A, Gelen MT, Duman O. Acute vanishing bile duct syndrome after the use of ibuprofen. Arab J Gastroenterol 2016; 17:137-139. [PMID: 27658326 DOI: 10.1016/j.ajg.2016.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Revised: 06/26/2015] [Accepted: 08/21/2016] [Indexed: 10/21/2022]
Abstract
We present a case report of a 7-year-old patient who developed toxic epidermal necrolysis (TEN) and vanishing bile duct syndrome (VBDS) after oral ibuprofen intake. Acute VBDS is a rare disease with unknown aetiology, often presenting with progressive loss of the intrahepatic biliary tract. TEN is an immune complex-mediated hypersensitivity reaction involving the skin and mucosa, which is induced by drugs or infectious diseases, sometimes leading to systemic symptoms. The patient in this case report was treated with supportive care, a steroid and ursodeoxycholic acid, with complete recovery observed by the end of the 8th month. This case report suggests that ibuprofen can cause acute vanishing duct syndrome.
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Affiliation(s)
- Ahmet Basturk
- Department of Paediatric Gastroenterology, Akdeniz University Faculty of Medicine, Dumlupinar Bulvari Campus, 07059 Antalya, Turkey.
| | - Reha Artan
- Department of Paediatric Gastroenterology, Akdeniz University Faculty of Medicine, Dumlupinar Bulvari Campus, 07059 Antalya, Turkey
| | - Aygen Yılmaz
- Department of Paediatric Gastroenterology, Akdeniz University Faculty of Medicine, Dumlupinar Bulvari Campus, 07059 Antalya, Turkey
| | - Mustafa T Gelen
- Department of Pathology, Akdeniz University Faculty of Medicine, Dumlupinar Bulvari Campus, 07059 Antalya, Turkey
| | - Ozgur Duman
- Department of Paediatric Neurology, Akdeniz University Faculty of Medicine, Dumlupinar Bulvari Campus, 07059 Antalya, Turkey
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Chen F, Tu XL. Revaluation of vanishing bile duct syndrome. Shijie Huaren Xiaohua Zazhi 2016; 24:3445-3453. [DOI: 10.11569/wcjd.v24.i23.3445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Vanishing bile duct syndrome (VBDS) can result from multiple etiologies, including congenital and genetic diseases, ischemic causes, neoplastic disorders, infections, immune disorders, drugs, idiopathic adulthood ductopenia (IAD) and so on. Recently, lymphoma, HIV/AIDS and drugs were identified to be major etiologies in the reported cases, some of which presented complex clinical course and were contributed by more than one etiological factor. Hepatic biopsy must be done for the diagnosis of VBDS and immunohistochemical staining for cytokeratin 7 (CK7) and CK19 has contributed to the establishment of diagnosis of VBDS. VBDS can be usually treated with symptomatic and supportive therapy, etiological therapy, liver transplantation, ursodeoxycholic acid and immunosuppressive agents. Glucocorticoids can be tried to switch to mycophemolate mofeil or tacrolimus when their effects are poor or side effects are severe. Severe cases ought to receive multimodality therapy besides plasmapheresis.
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20
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White JC, Appleman S. Infliximab/Plasmapheresis in vanishing bile duct syndrome secondary to toxic epidermal necrolysis. Pediatrics 2014; 134:e1194-8. [PMID: 25246624 PMCID: PMC4535040 DOI: 10.1542/peds.2013-2239] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Vanishing bile duct syndrome (VBDS) is a rare disorder characterized by loss of interlobular bile ducts and progressive worsening cholestasis. The acute presentation of this disease is typically associated with a drug hypersensitivity and Stevens-Johnson syndrome/toxic epidermal necrolysis (TEN). The mainstay of treatment has been ursodeoxycholic acid with mixed results from immunosuppressive regimens. Anti-tumor necrosis factor-α and plasmapheresis have been speculated to be of potential benefit. It is hoped that early identification and intervention in VBDS secondary to Stevens-Johnson syndrome/TEN with continued reporting will lead to better regimens and outcomes. Our case report details the first reported use of infliximab and plasmapheresis, in addition to steroids, in a patient with VBDS secondary to TEN, as well as a literature review that supports a mechanism for why these modalities could be effective treatments. Unfortunately, our patient died, and the use of these therapies had an unclear benefit on his liver and skin disease. We hope that additional work can be published to confirm or refute their utility in the treatment of these diseases.
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Affiliation(s)
| | - Stephanie Appleman
- Section of Gastroenterology, Department of Pediatrics, St Christopher's Hospital for Children, Philadelphia, Pennsylvania
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21
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Kim HY, Yang HK, Kim SH, Park JH. Ibuprofen associated acute vanishing bile duct syndrome and toxic epidermal necrolysis in an infant. Yonsei Med J 2014; 55:834-7. [PMID: 24719156 PMCID: PMC3990079 DOI: 10.3349/ymj.2014.55.3.834] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 06/17/2013] [Accepted: 07/31/2013] [Indexed: 11/27/2022] Open
Abstract
Acute vanishing bile duct syndrome, a rare but rapidly progressive destruction of the intrahepatic bile ducts with unknown pathogenesis, is most often a drug- or toxin-related. Toxic epidermal necrolysis is a serious dermatologic condition and a potentially life threatening disease, which is drug or infection induced. Ibuprofen associated acute vanishing bile duct syndrome and toxic epidermal necrolysis have not been reported previously in infants. We report a 7-month-old infant with ibuprofen associated toxic epidermal necrolysis, followed by severe and rapidly progressive vanishing bile duct syndrome. She recovered totally with supportive care.
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Affiliation(s)
- Hye-young Kim
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
- Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Hea Kyoung Yang
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
| | - Seong Heon Kim
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Jae Hong Park
- Department of Pediatrics, Pusan National University School of Medicine, Yangsan, Korea
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
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22
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Cho HJ, Jwa HJ, Kim KS, Gang DY, Kim JY. Urosodeoxycholic Acid Therapy in a Child with Trimethoprim-Sulfamethoxazole-induced Vanishing Bile Duct Syndrome. Pediatr Gastroenterol Hepatol Nutr 2013; 16:273-8. [PMID: 24511525 PMCID: PMC3915726 DOI: 10.5223/pghn.2013.16.4.273] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Revised: 10/22/2013] [Accepted: 10/28/2013] [Indexed: 11/30/2022] Open
Abstract
We present a case of a 7-year-old boy who had cholestasis after trimethoprim-sulfamethoxazole combination therapy. Liver biopsy was performed 36 days after the onset of jaundice because of no evidence of improving cholestasis. Liver histology revealed portal inflammation, bile plug, and biliary stasis around the central vein with the loss of the interlobular bile ducts. Immunohistochemical stains for cytokeratin 7 and 19 were negative. These findings were consistent with those of vanishing bile duct syndrome (VBDS). Chlestasis was progressively improved with dose increment of urosodeoxycholic acid from conventional to high dose. This is the first case report of trimethoprime-sulfamethoxazole associated VBDS in Korean children. The case suggests that differential diagnosis of VBDS should be considered in case of progressive cholestatic hepatitis with elevation of alkaline phosphatase and gamma-glutamyl transpeptidase after or during taking medicine to treat nonhepatobiliary diseases illness.
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Affiliation(s)
- Hyun Jeong Cho
- Department of Pediatrics, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hye Jeong Jwa
- Department of Pediatrics, Chungnam National University School of Medicine, Daejeon, Korea
| | - Kyu Seon Kim
- Department of Pediatrics, Chungnam National University School of Medicine, Daejeon, Korea
| | - Dae Yong Gang
- Department of Pathology, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae Young Kim
- Department of Pediatrics, Chungnam National University School of Medicine, Daejeon, Korea
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23
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Abstract
Nonsteroidal anti-inflammatory drugs are among the most prescribed medications worldwide. After antibiotics and anticonvulsants they are considered the most common medications associated with drug-induced liver injury mainly through an idiosyncratic form of hepatotoxicity. In rare cases severe hepatotoxicity has been described with significant morbidity and mortality. Genetic risk factors have been reported with diclofenac and lumiracoxib. Postmarketing surveillance and monitoring is crucial to identify severe cases of hepatotoxicity.
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Abstract
Cholestasis caused by drugs is an important differential diagnosis in patients presenting with a biochemical cholestatic pattern. The extent of serologic tests and radiological imaging depends on the clinical context. The underlying condition of the patient and detailed information on drug use, results of rechallenge, and the documented hepatotoxicity of the drug are important to establish a diagnosis of drug-induced liver injury (DILI). Most cases of cholestatic DILI are mild, but in rare cases, ductopenia and cholestatic cirrhosis can develop. Approximately 10% of patients with cholestatic jaundice caused by drugs develop liver failure.
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25
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Toki F, Takahashi A, Suzuki M, Ootake S, Hirato J, Kuwano H. Development of an experimental model of cholestasis induced by hypoxic/ischemic damage to the bile duct and liver tissues in infantile rats. J Gastroenterol 2011; 46:639-47. [PMID: 21350812 DOI: 10.1007/s00535-010-0330-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Accepted: 08/10/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND We aimed to develop experimental models of hypoxia/ischemia-induced cholestasis using neonatal and infantile rats. METHODS Hypoxia/ischemia was induced in the bile duct (BD) by injecting prostaglandin (PG) at birth and/or by coagulation of the hepatic artery (CHA) at about 3 weeks after birth. The rats were divided into 6 groups: control; PG-injected; sham-operated with or without PG; CHA; and CHA + PG. CHA was also performed in adult rats. Liver specimens and blood samples were obtained at 5 weeks after birth, and immunohistochemical and biochemical examinations were performed. RESULTS (1) BD proliferation with fibrosis (BDPF) was found in the intrahepatic portal tract in the CHA and CHA + PG groups. Low-grade BDPF was observed in the PG group. (2) Cyst formation in the extrahepatic BD (EBD) was observed in the porta hepatis of some rats in the CHA and CHA + PG groups. In these groups, the number of peribiliary vascular plexuses (PVPs) decreased. BD proliferation and infiltration of inflammatory cells were observed in the EBD wall in the CHA + PG group. (3) Ki-67 was expressed in BD and EBD cells in the CHA + PG group. (4) BDPF was not detected in adult rats with CHA. (5) Serum liver function tests indicated obstructive changes in the EBD in the CHA and CHA + PG groups. CONCLUSION Reduced blood flow in the EBD during infancy induced BDPF and obstructive changes in the EBD, which may, along with immature PVP and inflammatory changes in the EBD, contribute to hypoxia/ischemia of the EBD.
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Affiliation(s)
- Fumiaki Toki
- Pediatric Surgical Unit, Department of General Surgical Science, Gunma University Hospital, 3-39-15 Showa-machi, Maebashi, Gunma 371-8511, Japan.
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26
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Abstract
Recent progress in understanding the molecular mechanisms of bile formation and cholestasis have led to new insights into the pathogenesis of drug-induced cholestasis. This review summarizes their variable clinical presentations, examines the role of transport proteins in hepatic drug clearance and toxicity, and addresses the increasing importance of genetic determinants, as well as practical aspects of diagnosis and management.
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Affiliation(s)
- Manmeet S Padda
- Division of Gastroenterology, Centennial Hills Hospital Medical Center, Las Vegas, NV, USA
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27
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Gökçe S, Durmaz O, Celtik C, Aydogan A, Güllüoglu M, Sökücü S. Valproic acid-associated vanishing bile duct syndrome. J Child Neurol 2010; 25:909-11. [PMID: 20388938 DOI: 10.1177/0883073809343474] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hepatotoxicity as a result of valproic acid therapy is well documented. Elevation in aminotransferase activities is rarely associated with symptoms. It sometimes manifests as acute liver failure. Here, we report a 8-year-old girl who was referred for unresolving jaundice and itching for 3 months. Past history revealed afebrile convulsion 5 months previously and beginning of valproic acid treatment. Valproic acid was discontinued after the development of jaundice. Physical examination revealed ichterus, xanthomas on extensor surfaces of extremities, and hepatomegaly without any sign of chronic liver disease. Total and direct bilirubin levels were 20.2 and 12.9 mg/dL, respectively. Enzyme activities indicating cholestasis were increased together with blood cholesterol. Tests for infectious and autoimmune, metabolic, and genetic disorders were not informative. Liver biopsy revealed portal inflammation, severe bile duct loss, and cholestasis. The patient was considered to have valproic acid-associated vanishing bile duct syndrome, which has not been reported previously.
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Affiliation(s)
- Selim Gökçe
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Istanbul University, Istanbul Medical School, Fatih, Istanbul, Turkey.
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28
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Nanau RM, Neuman MG. Ibuprofen-induced hypersensitivity syndrome. Transl Res 2010; 155:275-93. [PMID: 20478543 DOI: 10.1016/j.trsl.2010.01.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Revised: 12/02/2009] [Accepted: 01/28/2010] [Indexed: 12/29/2022]
Abstract
Ibuprofen is a widely used antipyretic and analgesic nonsteroidal antiinflammatory drug (NSAID). With the aging of the population, there will be a significant increase in the prevalence of painful degenerative and inflammatory rheumatic conditions. This increase likely will lead to a parallel increase in the use of NSAIDs, including ibuprofen. The primary effect of the NSAIDs is to inhibit cyclooxygenase (prostaglandin synthase), thereby impairing the ultimate transformation of arachidonic acid to prostaglandins, prostacyclin, and thromboxanes. Although in the majority of cases it is safe, this NSAID, ibuprofen, can produce an unpredictable, idiosyncratic, type B reaction that may pose a major concern in clinical practice. Type B reactions are known to occur in susceptible individuals. The true hypersensitivity reaction (HSR) is a systemic disease defined by the triad of fever, rash, and internal organ involvement that starts 1 day to 12 weeks after the initiation of therapy. HSR has limited the therapeutic use of many drugs, including ibuprofen. Hypersensitivity syndrome associated with ibuprofen is a host-dependent drug reaction that is idiosyncratic in nature. This reaction likely is caused by a combination of metabolic and immunologic factors. Immune mediated components, such as T-cell and their products cytokines and chemokines, can exacerbate cellular responses and create complex pathways that lead to a variety of clinical manifestations. Our review presents an ibuprofen-induced clinical manifestation of hypersensitivity syndrome and the necessity of wisely monitoring the patients clinically and by laboratory investigations when prescribing this drug.
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Affiliation(s)
- Radu M Nanau
- Department of In Vitro Drug Safety and Biotechnology and the Department of Pharmacology and Toxicology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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29
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Ward KE, Archambault R, Mersfelder TL. Severe adverse skin reactions to nonsteroidal antiinflammatory drugs: A review of the literature. Am J Health Syst Pharm 2010; 67:206-13. [DOI: 10.2146/ajhp080603] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Kristina E. Ward
- College of Pharmacy, University of Rhode Island, Kingston. LT USN MSC
| | - Raoul Archambault
- Department of Pharmacy, Robert E. Bush Naval Hospital, Twentynine Palms, CA; at the time of writing he was a student, College of Pharmacy, University of Rhode Island
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30
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Juricic D, Danica J, Hrstic I, Irena H, Radic D, Davor R, Skegro M, Mate S, Coric M, Marijana C, Vucelic B, Boris V, Francetic I, Igor F. Vanishing bile duct syndrome associated with azithromycin in a 62-year-old man. Basic Clin Pharmacol Toxicol 2009; 106:62-5. [PMID: 19906050 DOI: 10.1111/j.1742-7843.2009.00474.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Vanishing bile duct syndrome is a severe cholestatic disease associated with toxic effects of medications. Stevens-Johnson syndrome is a hypersensitivity disorder that may also be caused by medications. We present a case of a 62-year-old male patient who developed vanishing bile duct syndrome a month after Stevens-Johnson syndrome. These adverse drug reactions were associated with the use of azithromycin (500 mg daily for 3 days). The patient was initially treated for Stevens-Johnson syndrome with steroids, antihistamines and proton pump inhibitors and fully recovered. However, a month after the beginning of Stevens-Johnson syndrome, he developed vanishing bile duct syndrome and was treated with steroids, ursodeoxycholic acid, antihistamines and tacrolimus. Unfortunately, the treatment was unsuccessful and he was listed for liver transplantation which was performed 7 months after the beginning of jaundice. This is the first case of vanishing bile duct syndrome associated with the use of azithromycin and one of few that reports vanishing bile duct syndrome and Stevens-Johnson syndrome co-occurrence.
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Affiliation(s)
- Danica Juricic
- Division of Clinical Pharmacology, Department of Internal Medicine, Zagreb University Hospital Center, Zagreb, Croatia.
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31
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Okan G, Yaylaci S, Peker O, Kaymakoglu S, Saruc M. Vanishing bile duct and Stevens-Johnson syndrome associated with ciprofloxacin treated with tacrolimus. World J Gastroenterol 2008; 14:4697-700. [PMID: 18698687 PMCID: PMC2738797 DOI: 10.3748/wjg.14.4697] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Stevens-Johnson syndrome (SJS) is a serious and potentially life-threatening disease. Vanishing bile duct syndrome (VBDS) is a rare cause of progressive cholestasis. Both syndromes are mostly related with drugs. We report a case of a patient with ciprofloxacin-induced SJS and acute onset of VBDS, and reviewed the related literature. It is the first case of ciprofloxacin-induced VBDS successfully treated with tacrolimus. This case reminds physicians of the importance of drug reactions, their severity, techniques for diagnosis and methods of management.
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32
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Elkrief L, Chryssostalis A, Moachon L, Franck N, Terris B, Chaussade S, Sogni P. [Severe cholestatic hepatitis associated with Stevens-Johnson syndrome after taking ibuprofen]. ACTA ACUST UNITED AC 2008; 31:1043-5. [PMID: 18166906 DOI: 10.1016/s0399-8320(07)78331-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Tajiri H, Etani Y, Mushiake S, Ozono K, Nakayama M. A favorable response to steroid therapy in a child with drug-associated acute vanishing bile duct syndrome and skin disorder. J Paediatr Child Health 2008; 44:234-6. [PMID: 18377375 DOI: 10.1111/j.1440-1754.2008.01291.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Perhaps no condition associated with chronic cholestasis is less understood than vanishing bile duct syndrome, a term that refers loosely to the group of acquired disorders associated with progressive destruction and disappearance of the intrahepatic bile ducts and, ultimately, cholestasis. Although the array of insults resulting in poor bile flow is vast, most adult patients who have chronic cholestasis have either primary biliary cirrhosis (or primary sclerosing cholangitis; in some cases, however, a cause cannot be identified. This article reviews the multiple causes, postulated pathophysiology, clinical features, and treatment options for this syndrome.
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Affiliation(s)
- Nancy S Reau
- Center for Liver Diseases, Section of Gastroenterology, Department of Medicine, University of Chicago Medical Center, 5841 S. Maryland, MC7120, Chicago, IL 60637, USA.
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35
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Morbidity and Mortality of Mucocutaneous Diseases in the Pediatric Population at a Tertiary Care Center. J Burn Care Res 2007; 28:865-70. [DOI: 10.1097/bcr.0b013e318159a3c7] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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36
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Affiliation(s)
- Junji Takeyama
- Department of Pathology, Miyagi Children's Hospital, Sendai, Japan.
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37
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Treinen-Moslen M, Kanz MF. Intestinal tract injury by drugs: Importance of metabolite delivery by yellow bile road. Pharmacol Ther 2006; 112:649-67. [PMID: 16842856 DOI: 10.1016/j.pharmthera.2006.05.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2006] [Accepted: 05/17/2006] [Indexed: 02/07/2023]
Abstract
Drug secretion into bile is typically considered a safe route of clearance. However, biliary delivery of some drugs or their reactive metabolites to the intestinal tract evokes adverse consequences due to direct toxic actions or indirect disruption of intestinal homeostasis. Biliary concentration of the chemotherapy agent 5-fluorodeoxyuridine (FUDR) and other compounds is associated with bile duct damage while enterohepatic cycling of antibiotics contributes to the disruptions of gut flora that produce diarrhea. The goal of this review is to describe key evidence that biliary delivery is an important factor in the intestinal injury caused by representative drugs. Emphasis will be given to 3 widely used drugs whose reactive metabolites are plausible causes of small intestinal injury, namely the nonsteroidal anti-inflammatory drug (NSAID) diclofenac, the immunosuppressant mycophenolic acid (MPA), and the chemotherapy agent irinotecan. Capsule endoscopy and other sensitive diagnostic techniques have documented a previously unappreciated, high prevalence of small intestinal injury among NSAID users. Clinical use of MPA and irinotecan is frequently associated such severe intestinal injury that dosage must be reduced. Observations from clinical and experimental studies have defined key events in the pathogenesis of these drugs, including roles for multidrug resistance-associated protein 2 (MRP2) and other transporters in biliary secretion and adduction of enterocyte proteins by reactive acyl glucuronide metabolites as a likely mechanism for intestinal injury. New strategies for minimizing the adverse intestinal consequences of irinotecan chemotherapy illustrate how basic information about key events in the biliary secretion of drugs and the nature of their proximate toxicants can lead to safer protocols for drugs.
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Affiliation(s)
- Mary Treinen-Moslen
- Departments of Pathology and Internal Medicine, University of Texas Medical Branch, 1108 Strand St Building, Room 105, 300 University Boulevard, Galveston, TX 77555-0632, USA.
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38
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Abstract
Severe gastrointestinal tract involvement is a rare manifestation of Stevens-Johnson syndrome (SJS). The case is described of a 17 year old man who developed SJS secondary to phenytoin. In addition to the cutaneous, ocular, and oral mucosal lesions typical of SJS, he also developed persistent, bloody diarrhoea associated with life threatening malnutrition. Serial colonoscopy showed severe and progressive colitis. He was treated with a combination of long term nutritional support, probiotic therapy, and supportive measures. He was eventually discharged from hospital six months after admission when the diarrhoea improved and he began to gain weight.
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Affiliation(s)
- N Powell
- Department of Gastroenterology, Queen Elizabeth Hospital, London, UK.
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Karnsakul W, Arkachaisri T, Atisook K, Wisuthsarewong W, Sattawatthamrong Y, Aanpreung P. Vanishing bile duct syndrome in a child with toxic epidermal necrolysis: an interplay of unbalanced immune regulatory mechanisms. Ann Hepatol 2006. [PMID: 16807519 DOI: 10.1016/s1665-2681(19)32029-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Vanishing bile duct syndrome (VBDS) is a rare disorder and requires a liver biopsy for a diagnosis. The condition has not been reported in children with toxic epidermal necrolysis (TEN). The etiology of VBDS in our patient with TEN is most likely from drug hypersensitivity. A high index of suspicion will prompt clinicians to start more specific investigations and treatments. The use of immunosuppressive agents, intravenous immunoglobulin and ursodeoxycholic acid has not been consistently successful in these patients. A new approach with biologic agents such as anti-tumor necrosis factor-alpha may be a promising therapy and reduce severe adverse outcomes.
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Affiliation(s)
- Wikrom Karnsakul
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV 26506-9214, USA.
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Cogrel O, Duffau P, Beylot-Barry M, Robert A, Orlandini V, Doutre M, Sanchez R, Beylot C. P23 - Nécrolyse épidermique toxique et ductopénie secondaires à la prise d’ibuprofène : troisième observation. Ann Dermatol Venereol 2005. [DOI: 10.1016/s0151-9638(05)79752-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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41
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Smith LA, Ignacio JRA, Winesett MP, Kaiser GC, Lacson AG, Gilbert-Barness E, González-Peralta RP, Wilsey MJ. Vanishing bile duct syndrome: amoxicillin-clavulanic acid associated intra-hepatic cholestasis responsive to ursodeoxycholic acid. J Pediatr Gastroenterol Nutr 2005; 41:469-73. [PMID: 16205517 DOI: 10.1097/01.mpg.0000178086.44155.73] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- L A Smith
- Department of Pediatrics, University of South Florida College of Medicine, Tampa, Florida 33617, USA
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42
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Sánchez-Borges M, Capriles-Hulett A, Caballero-Fonseca F. Risk of skin reactions when using ibuprofen-based medicines. Expert Opin Drug Saf 2005; 4:837-48. [PMID: 16111447 DOI: 10.1517/14740338.4.5.837] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Adverse reactions to drugs are a frequent cause of morbidity and medical consultation; it is no surprise that nonsteroidal anti-inflammatory drugs (NSAIDs) run second, after antibiotics, mainly of the beta-lactam group (penicillins and cephalosporins). Numerous clinical pictures involving the skin--various morbilliform rashes, urticaria and angioedema as the most common--due to hypersensitivity to a particular NSAID (i.e., ibuprofen) have been described; other clinically defined skin diseases such as vasculitis, Steven-Johnson's syndrome, photosensitivity, fixed drug eruptions, livedo-like dermatitis, linear drug eruption, lichenoid drug eruption, exanthematous pustulosis, eczematous eruption, contact dermatitis and pemphigoid have received the attention of physicians. Extensive use around the world makes it interesting to investigate adverse cutaneous reactions to ibuprofen and other members of the propionic acid derivative group, to ascertain their prevalence, clinical presentation and prevention. This paper presents a review of published literature concerning cutaneous hypersensitivity reactions to ibuprofen and related arylpropionic acids.
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Affiliation(s)
- Mario Sánchez-Borges
- Centro Médico-Docente La Trinidad, Allergy and Immunology Service, Caracas, Venezuela.
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43
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Taghian M, Tran TA, Bresson-Hadni S, Menget A, Felix S, Jacquemin E. Acute vanishing bile duct syndrome after ibuprofen therapy in a child. J Pediatr 2004; 145:273-6. [PMID: 15289784 DOI: 10.1016/j.jpeds.2004.05.027] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We report the case of a 10 year-old girl who had Stevens-Johnson syndrome and cholestasis after ibuprofen therapy. Liver histology was compatible with vanishing bile duct syndrome. She received ursodeoxycholic acid, and liver tests normalized within 7 months. This report confirms that ibuprofen may induce acute vanishing bile duct syndrome.
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Affiliation(s)
- M Taghian
- Pediatric Unit, Vesoul Hospital, Vesoul, France
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44
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Jacquet JM, Geynet AC, Vanlemmens C, Kantelip B, Miguet JP, Bresson-Hadni S. [Ibuprofen induced acute cholangitis]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2004; 28:821-2. [PMID: 15646550 DOI: 10.1016/s0399-8320(04)95140-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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45
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Abstract
Cholestasis caused by medicinal and chemical agents is an increasingly well-recognized cause of liver disease. Clinical drug-induced cholestatic syndromes producing jaundice and bile duct injury can mimic extrahepatic biliary obstruction, primary biliary cirrhosis, and sclerosing cholangitis, among others. This article updates the various forms of drug-induced cholestasis, focusing on the clinicopathologic features of this form of hepatic injury and on the known or putative mechanisms by which drugs and chemicals lead to cholestasis.
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Affiliation(s)
- Raja Mohi-ud-din
- Section of Hepatology, Division of Gastroenterology, Georgetown University Medical Center, 3800 Reservoir Road, Washington, DC 20007, USA
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46
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Abstract
NSAIDs are one of most frequently prescribed agents in clinical practice. Whereas hepatotoxicity is a rare complication of most NSAIDs (typically 1 to 10 per 100,000 persons exposed), the high level of usage means that these drugs cause liver disease. Because of their divergent chemical structures, the mechanisms and clinicopathological manifestations of hepatotoxicity vary widely. The reactive metabolite syndrome, in which serious rash, eosinophilia, and other forms of tissue injury are common, may be incited by several NSAIDs, including newer agents. Women, people aged more than 50 years, and for some drugs, the type of arthritis, may be risk factors for drug-induced liver injury. The spectrum of NSAID-drug related hepatotoxicity continues to expand, with reports of interactive toxicity in adults with hepatitis C and recognition of rare cases of liver disease associated with non-selective, selective, and preferential COX-2 inhibitors. Better outcomes require people taking NSAIDs to be aware of possible drug reactions involving the liver, and prescribers should be vigilant for early symptoms of hepatotoxicity so that incriminated agents are discontinued promptly.
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Affiliation(s)
- Narci C Teoh
- Storr Liver Unit, Westmead Millennium Institute, University of Sydney at Westmead Hospital, Darcy Road, PO Box 412, Westmead, New South Wales 2145, Australia
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47
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Abstract
Drug-induced cholestasis is a common entity, seen with numerous classes of pharmacological agents. A high index of suspicion is required for the correct diagnosis. Different clinical syndromes may be recognized, with variable degrees of hepatitis in association with cholestasis. The most important aspect of treatment is prompt discontinuation of the offending drug. Several agents have been used for symptomatic relieve of the pruritus associated with cholestasis, including cholestyramine, ursodeoxycholic acid, and opiate antagonists, with limited results. Prognosis is usually good, with few cases of prolonged cholestasis leading to vanishing bile duct syndrome. Liver failure may rarely occur if diagnosis goes unrecognized and the inciting drug is not withdrawn.
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Affiliation(s)
- Cynthia Levy
- Division of Gastroenterology and Hepatology, W 19A, Mayo Clinic and Foundation, 200 1st Street, SW, Rochester, MN 55905, USA
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48
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Abstract
Drug-induced bile duct injury related prolonged or chronic cholestasis is recognized as a common side effect of treatment with several drugs. The severity and duration of the clinical symptoms suggest that this increase in number of reports is not only related to clinician and pathologists being increasingly aware of the condition, but also may represent a true increase in incidence likely related to a time-related growing experience with newer drugs. This clinical presentation encompasses a wide variety of features that may be the source of diagnostic difficulties, especially in the cases where cholestasis occurs days or weeks after the completion of therapy. Even more puzzling is the initial picture of hepatocholangitis, which may be silent and ensuing bile duct paucity with chronic anicteric cholestasis may be another source of diagnostic difficulties in the long-term. These diagnostic difficulties suggest that some of the cases of the so-called "idiopathic adulthood ductopenia" may originate from overlooked drug induced vanishing bile duct syndrome. The pathogenesis of the syndrome remains largely unknown and the determinants of prognosis and outcome. From reproducible data obtained in different studies investigating HLA-dependent predisposition, one may assume that genetics plays a major role even if other unknown additive factors are also likely involved. Severity of initial hepatocholangitis is likely to represent another important determinant of severity and prognosis, however to be assessed in larger longitudinal studies. Therapy of large bile duct injury mimics that of primary sclerosing cholangitis. Treatment of small bile duct injury remains disappointing. Corticosteroids are invariably ineffective. Ursodeoxycholic acid as been shown to induce improvement of clinical and biochemical cholestasis in some selected cases, its efficacy being however unpredictable. Preliminary data about the natural history of the vanishing bile duct syndrome suggest that therapy might be more effective when initiated early.
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Affiliation(s)
- André P Geubel
- Department of Gastroenterology, St. Luc University Hospital, Université Catholique de Louvain 10, Avenue Hippocrate, 1200 Brussels, Belgium.
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49
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Ozkan A, Yoruk A, Celkan T, Apak H, Yildiz I, Ozbay G. The vanishing bile duct syndrome in a child with Hodgkin disease. MEDICAL AND PEDIATRIC ONCOLOGY 2001; 36:398-9. [PMID: 11241447 DOI: 10.1002/mpo.1096] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- A Ozkan
- Department of Pediatric Hematology-Oncology, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey.
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50
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