Lymphocyte stimulation induced by halothane in patients with hepatitis following exposure to halothane

Postpericardiotomy syndrome after cardiac surgery

Postpericardiotomy syndrome (PPS) is a well-known complication after cardiac surgery. The syndrome results in prolonged hospital stay, readmissions, and invasive interventions. Previous studies have reported inconsistent results concerning the incidence and risk factors for PPS due to the differences in the applied diagnostic criteria, study designs, patient populations, and procedure types. In recent prospective studies the reported incidences have been between 21 and 29% in adult cardiac surgery patients. However, it has been stated that most of the included diagnoses in the aforementioned studies would be clinically irrelevant. This challenges the specificity and usability of the currently recommended diagnostic criteria for PPS. Moreover, recent evidence suggests that PPS requiring invasive intervention such as the evacuation of pleural and/or pericardial effusion is associated with increased mortality. In the present review, we summarise the existing literature concerning the incidence, clinical features, diagnostic criteria, risk factors, management, and prognosis of PPS. We also propose novel approaches regarding to the definition and diagnosis of PPS. Key messages: Current diagnostic criteria of PPS should be reconsidered, and the analyses should be divided into subgroups according to the severity of the syndrome to achieve more clinically applicable and meaningful results in the future studies. In contrast with the previous presumption, severe PPS - defined as PPS requiring invasive interventions - was recently found to be associated with higher all-cause mortality during the first two years after cardiac surgery. The association with an increased mortality supports the use of relatively aggressive prophylactic methods to prevent PPS. The risk factors clearly increasing the occurrence of PPS are younger age, pleural incision, and valve and ascending aortic procedures when compared to CABG.

Phenobarbital-Induced Hepatic Dysfunction

Phenobarbital has infrequently been reported to cause hepatitis. The previously reported cases of barbiturate-induced jaundice are reviewed and data from two previously unreported cases are presented. A discussion of mechanisms of iatrogenic hepatotoxicity is presented with emphasis on idiosyncratic mechanisms. Hepatitis secondary to phenobarbital administration appears to be due to a hypersensitivity reaction. This mechanism seems most likely because of the commonly seen clinical picture of rash, fever and eosinophilia.

Speculation is made that phenobarbital hepatitis is possibly more common than the small number of reported cases would indicate. Criteria for the assessment and treatment of this iatrogenic disease are presented.

Renal Tubular Necrosis and Liver Damage

A 40-year-old woman developed renal tubular necrosis and liver injury following ingestion of acetaminophen 1 g 12 days after halothane anesthesia. The possibility of a synergistic association between halothane and acetaminophen, and of probable hepatic and renal damage occurring after a low dose of acetaminophen, as well as the possibility of renal tubular necrosis induced by halothane are discussed.

Aseptic meningitis in mixed connective tissue disease: cytokine and anti-U1RNP antibodies in cerebrospinal fluids from two different cases

In this paper, we report two patients with mixed connective tissue disease (MCTD) who developed aseptic meningitis. In both cases, the concentrations of IFN-gamma and IL-6 in cerebrospinal fluid (CSF) were increased. In the first case, with non-steroidal anti-inflammatory drugs (NSAIDs)-induced meningitis, where anti-U1RNP antibodies (Abs) were not detected in CSF, NSAIDs induced both IFN-gamma and IL-6 secretion from peripheral blood mononuclear cells in vitro. In the second case, with disease-associated meningitis, anti-U1RNP Abs were detected also in CSF. Of note, anti-U1RNP Abs appeared to be more concentrated in CSF than in serum and CSF-anti-U1RNP Ab titer was correlated with disease activity. We suggest that IFN-gamma and IL-6 may be involved in both disease-associated and drug-induced aseptic meningitis, whereas CSF-anti-U1RNP Abs is detected only in a patient with MCTD-associated aseptic meningitis.

Interstitial pneumonia induced by ticlopidine

A 67-year-old female non-smoker, who had been diagnosed with familial hypercholesterolemia associated with severe atherosclerosis of the coronary, carotid and vertebral arteries, developed interstitial pneumonia 4 months after initiating ticlopidine to inhibit platelet aggregation. The lymphocyte stimulation test by ticlopidine was positive and bronchoalveolar lavage fluid showed an increase in lymphocytes and a decrease in the CD4+/8+ ratio, suggesting potentially undesirable side effects of ticlopidine. Two months after ticlopidine therapy was discontinued and prednisolone therapy started, the interstitial pneumonia had almost completely resolved. Two patients, one with ticlopidine-associated bronchiolitis obliterans organizing pneumonia and the other with pneumonia with multiple nodules, have been reported to date and the present patient is the third reported case of ticlopidine-induced pneumonia. The incidence of this side effect may not be so high because approximately 20 years have passed since ticlopidine was first marketed in Japan, but because the drug is now widely prescribed, this serious clinical side effect should be considered.

Halothane-induced liver injury in outbred guinea pigs: role of trifluoroacetylated protein adducts in animal susceptibility

Halothane causes a mild form of liver injury in guinea pigs that appears to model the hepatotoxicity seen in approximately 20% of patients treated with this drug. In previous studies, it was concluded that the increased susceptibility of some outbred guinea pigs to halothane-induced liver injury is not caused by their inherent ability to metabolize halothane to form toxic levels of trifluoroacetylated protein adducts in the liver. In this study, we reevaluated the role of trifluoroacetylated protein adducts in halothane-induced liver injury in guinea pigs. Male outbred Hartley guinea pigs were treated with halothane intraperitoneally. On the basis of serum alanine aminotransferase levels and liver histology, treated animals were designated as being susceptible, mildly susceptible, or resistant to halothane. Immunoblot studies with the use of anti-trifluoroacetylated antibodies showed that susceptible guinea pigs for the most part had higher levels of trifluoroacetylated protein adducts in the liver 48 h after treatment with halothane than did less susceptible animals. In support of this finding, the level of trifluoroacetylated protein adducts detected immunochemically in the sera of treated guinea pigs correlated with sera levels of alanine aminotransferase activity. In addition, the levels of cytochrome P450 2A-related protein but not those of other cytochrome P450 isoforms, measured by immunoblot analysis with isoform-specific antibodies, correlated with the amount of trifluoroacetylated protein adducts detected in the livers of guinea pigs 8 h after halothane administration. The results of this study indicate that the susceptibility of outbred guinea pigs to halothane-induced liver injury is related to an enhanced ability to metabolize halothane in the liver to form relatively high levels of trifluoroacetylated protein adducts. They also suggest that cytochrome P450 2A-related protein might have a major role in catalyzing the formation of trifluoroacetylated protein adducts in the liver of susceptible guinea pigs. Similar mechanisms may be important in humans.

Drug-induced immunotoxicity

Immune-related drug responses are one of the most common sources of idiosyncratic toxicity. A number of organs may be the target of such reactions; however, this review concentrates mostly on the liver. Drug-induced hepatitis is generally divided into two categories: acute hepatitis in which the drug or a metabolite destroys a vital target in the cell; immunoallergic hepatitis in which the drug triggers an adverse immune response directed against the liver. Their clinical features are: a) low frequency; b) dose independence; c) typical immune system manifestations such as fever, eosinophilia; d) delay between the initiation of treatment and onset of the disease; e) a shortened delay upon rechallenge; and f) occasional presence of autoantibodies in the serum of patients. Such signs have been found in cases of hepatitis triggered by drugs such as halothane, tienilic acid, dihydralazine and anticonvulsants. They will be taken as examples to demonstrate the recent progress made in determining the mechanisms responsible for the disease. The following mechanisms have been postulated: 1) the drug is first metabolized into a reactive metabolite which binds to the enzyme that generated it; 2) this produces a neoantigen which, once presented to the immune system, might trigger an immune response characterized by 3) the production of antibodies recognizing both the native and/or the modified protein; 4) rechallenge leads to increased neoantigen production, a situation in which the presence of antibodies may induce cytolysis. Toxicity is related to the nature and amount of neoantigen and also to other factors such as the individual immune system. An effort should be made to better understand the precise mechanisms underlying this kind of disease and thereby identify the drugs at risk; and also the neoantigen processes necessary for their introduction into the immune system. An animal model would be useful in this regard.

Demonstration of a cellular immune response in halothane-exposed guinea pigs

Halothane hepatitis is considered to be a result of an idiosyncratic autoimmune reaction brought about by the formation of neoantigens that have been generated by covalent binding of halothane biotransformation intermediates. The guinea pig is being examined as an animal model to investigate an immune-mediated mechanism for halothane hepatotoxicity. Male Hartley guinea pigs were exposed to 1% halothane/40% oxygen for 4 hr, three times with 40-day intervals. Kupffer cells and splenocytes were isolated from animals on various days after each halothane exposure. Splenocytes were cocultured in a lymphocyte transformation test with various concentrations of TFA(trifluoroacetylated)-antigens for 7 days and proliferation was measured by 3H-thymidine incorporation. In a second experiment, Kupffer cells were cocultured with autologous as well as allogeneic splenocytes with or without concanavalin A to determine whole cell sensitization and accessory function by Kupffer cells from treated animals. A 4-fold increase in splenocyte proliferation occurred in response to TFA-guinea pig albumin. No significant increase in proliferation could be detected with TFA-lysine or guinea pig albumin. A 14-fold increase in splenocyte proliferation also occurred in response to Kupffer cells from halothane-exposed animals. Autologous splenocytes demonstrated more of a response from treated versus control animals, indicating possible involvement of major histocompatibility complex II antigens. These results indicate recognition of TFA-antigens and Kupffer cells as antigen-presenting cells in halothane-exposed guinea pigs. This study provides good evidence that a cellular immune response is involved in the guinea pig after halothane exposure.

Immunotoxicology of the liver: adverse reactions to drugs

Liver is a frequent target for drug-induced hepatitis. They can be classified in two categories: the hepatitis in which the drug or a metabolite reach a vital target in the cell and the hepatitis in which the drug triggers an adverse immune response directed against the liver. We will discuss essentially this second kind of disease. They have key clinical features such as the low frequency, the dose independence, the delay between the beginning of drug intake and the triggering of the disease, the shortening of the delay upon rechallenge and very often the presence of autoantibodies in the serum of the patients. Such signs were found in hepatitis triggered by drugs such as halothane, tienilic acid, dihydralazine, anticonvulsants. They will be taken as examples to show the recent progress in the understanding of the mechanisms leading to the disease. It has been postulated that the drug is metabolised into a reactive metabolite binding to the enzyme which generated it; therefore the neoantigen might trigger an immune response characterised by the production of antibodies recognising the native and or the modified protein. Most of these steps were proven in the cases of halothane, tienilic acid and dihydralazine. Several points seem important in the development of the disease; the equilibrium between toxication and detoxication pathways, the nature and amount of neoantigen, the individual immune response. However, many points remain unclear: for instance, the reason for the very low frequency of this kind of disease; the precise mechanism of the adverse immune response; the risk factors for developing such adverse reactions. Efforts should be made to better understand the mechanisms of this kind of disease: for instance, an animal model, tests to identify drugs at risk for such reactions, the role of these drugs in the processing of P450s and the processing of the neoantigens for their presentation to the immune system.

Cytochromes P450 and UDP-glucuronosyl-transferases as hepatocellular autoantigens

Autoantibodies directed against cytochromes P450 or UDP-glucuronosyl-transferases (UGTs) are detected in hepatitis of different aetiology: drug-induced hepatitis autoimmune hepatitis type 2, hepatitis associated with the autoimmune polyglandular syndrome type 1 (APS1) and virus-induced autoimmunity. Autoantibodies directed against cytochrome P450 2C9 are induced by tienilic acid, and anti-P450 1A2 autoantibodies by dihydralazine. Potential mechanisms involved may be metabolic activation of the drugs by cytochromes P450, adduct formation and circumvention of T cell tolerance. In contrast, little is known about the aetiology of autoimmune hepatitis type 2. This disease is characterized by marked female predominance, hypergammaglobulinaemia, circulating autoantibodies and benefit from immunosuppression. Patients with HLA B8, DR3 or DR4 are over-represented. The major target of autoimmunity in this disease is cytochrome P450 2D6. The autoantibodies were shown to be directed against at four short linear epitopes. In addition, about 10% of the patient sera form an additional autoantibody that detects a conformational epitope on UGTs of family 1. The phenomenon of virus-associated autoimmunity is found in chronic infections with hepatitis C and D. In chronic hepatitis C the major target of the autoantibodies again is cytochrome P450 2D6. Some linear and a high proportion of conformational epitopes are recognized. The LKM3 autoantibody is found in 13% of patients with chronic hepatitis D. The target proteins are UGTs of family 1 and, in some sera also, low titres of anto-antibodies directed against UGTs of family 2 are found. The epitopes detected are conformational. In contrast to the patients suffering from autoimmune hepatitis, patients with hepatitis as part of the autoimmune polyglandular syndrome type 1 recognize cytochrome P450 1A2. Interestingly, in APS1 patients also, autoantibodies directed against cytochromes P450 c21, P450 scc and P450 c17a may be detected; these autoantibodies are associated with adrenal and ovarian failure.

Carbamazepine-induced thrombocytopenia and carbamazepine-10,11-epoxide: a case report

The case of a patient who developed thrombocytopenia during treatment with carbamazepine (CBZ) is described. The platelet count recovered soon after discontinuation of CBZ, Lymphocyte stimulation test with carbamazepine-10, 11-epoxide (CBZ-10, 11-EPOX), a major metabolite of CBZ, was positive, although with CBZ it was negative. These findings suggest that CBZ-10, 11-EPOX was possibly causative in the pathogenesis of CBZ-induced thrombocytopenia in this case.

Two cases of recurrent hepatic injury associated with early pregnancy: hCG on hepatocytes is a suspected target antigen for lymphocyte attack

Two cases of recurrent hepatic injury which appeared in the first trimester of pregnancy were studied. Case 1 was a 35 year old woman, gravida 4, para 0, who suffered repeatedly from hepatic injury requiring induced abortions. The patient was healthy before the pregnancies and the plasma aminotransferases increased after 8 weeks gestation and promptly returned to normal after the abortions. No fluctuation of aminotransferases was observed in the menstrual cycle. A liver biopsy immediately after abortion showed spotty necrosis of hepatocytes with mononuclear cell infiltration. Most of the infiltrating cells were cytotoxic T cells that were directly in contact with hepatocytes. Numerous lymphocytic infiltrations were also found in the decidua of the uterine curettage material. The patient's lymphocytes showed conspicuous blast transformation in culture with human chorionic gonadotropin (hCG). The hCG was detected in close vicinity to the injured hepatocytes by immunostaining. Case 2 was a 23 year old woman, gravida 2, para 0, who underwent an induced abortion due to hepatic dysfunction in the first pregnancy. Although hepatic dysfunction reappeared from 10 weeks gestation during the second pregnancy, her health gradually improved with conservative therapy and resulted in a full-term delivery. She lacked allergies to drugs or foods and was healthy when she was not pregnant. These two cases suggest that some hepatotoxic materials appeared transiently in the first trimester. The results of Case 1 suggest strongly that hCG on the hepatocytes was recognized as an antigen and evoked lymphocytic attack.

Acetaminophen-induced eosinophilic pneumonia

We present the first case (to our knowledge) of acetaminophen-induced eosinophilic pneumonia. Although the patient had taken an acetaminophen-containing combination drug, Kinuya-chinnetsu, for only three days, the abnormal shadow on his chest radiograph continued for about a month. Lymphocyte stimulation tests showed that both Kinuya-chinnetsu and acetaminophen induced the proliferation of peripheral blood lymphocytes.

Hepatotoxicity and inhalation anesthetics: views in the era of isoflurane

The halogenated inhalation anesthetics continue to be an important group of drugs in current anesthesia practice. The purpose of this article is to discuss current concepts of the mechanisms of halothane-induced hepatotoxicity and to attempt to answer the question: Do all halogenated inhalation anesthetics share halothane's propensity to hepatotoxicity?

The epidemiology of the postpericardiotomy syndrome: a common complication of cardiac surgery

PPS is a major cause of morbidity after cardiac surgery and may cause bypass graft closure and fatal cardiac tamponade. Little is known about its incidence and cause. To better define this syndrome characterized by postoperative fever, pericardial friction rub, and pericardial pain, we used two out of three of the preceding criteria to diagnose PPS. In a prospective epidemiologic study we followed 944 consecutive patients undergoing open-heart surgery between November 1984 and November 1985. The overall incidence was 17.8%. The incidence was increased in younger patients, in those with a history of prednisone use in the past, in patients with a past history of pericarditis, those with aortic valve replacement, and in patients who received enflurane or halothane anesthesia. PPS is a common syndrome. Knowledge of risk factors associated with PPS may allow its prevention and identification of patients who warrant early and aggressive treatment.

The specificity of the lymphocyte transformation test in a patient with hypersensitivity reactions to pyrazolone compounds. A 10-week follow-up study before and after rechallenge

To evaluate the specificity of the lymphocyte transformation test (LTT) in the diagnosis of drug allergy we studied over 71 days an atopic woman with a past history of frequent adverse reactions to pyrazolone drugs. Rechallenge with the incriminated substances aminophenazone (aminopyrine) and propyphenazone was carried out on Days 11 and 31 respectively. An immediate type of hypersensitivity reaction was seen after 100 mg aminophenazone, while 100 mg of propyphanozone led to a serum sickness-like syndrome. We found two specifically sensitized lymphocyte populations using either the pure substance or sera containing metabolite in cell cultures. Stimulatory responses with indices ranging between 3 and 6 were seen 3-4 days after exposure, and the tests remained positive in both instances for 3-4 weeks. Specific sensitization was proven by positive skin tests and by a small but distinct lymphocyte proliferative response before challenge. Several lymphocyte function tests were performed over a period of 53 days and revealed a large fall in pokeweed mitogen-induced immunoglobulin synthesis and an increase in suppressor cell activity after rechallenge with aminophenazone. We conclude that the proliferative response observed in the presence of the offending drug is due to the activation of T memory cells and therefore highly suggestive of a true allergic reaction.

A case of salicylazosulfapyridine (Salazopyrin)-induced acute pancreatitis with positive lymphocyte stimulation test (LST)

A case of acute pancreatitis induced by salicylazosulfapyridine (Salazopyrin, SASP) was reported. A 33-year-old man with ulcerative colitis was given SASP. Five weeks later, P-type serum amylase was found to be elevated. The amylase/creatinine clearance ratio (ACCR) and serum lipase were also elevated. There were neither subjective symptoms nor abnormal ultrasound findings in the pancrease. Lymphocyte stimulation test (LST) to SASP was positive. Asymptomatic pancreatitis by SASP was suspected and SASP administration was halted. Afterwards the abnormal data became normal. Readministration of SASP because of relapse caused an episode of pancreatitis similar to the first occasion. LST was negative before SASP intake and became positive after intake. Desensitization to SASP was unsuccessful. LST was negative before attempting desensitization and became positive when the dosage of SASP increased to 100 mg daily. This is the second case of acute pancreatitis reported to be induced by SASP and this is the first case in which LST to SASP was described. To our knowledge, this is also the first case in which a positive LST was described in drug-induced pancreatitis. This case provides evidence for the role of delayed type hypersensitivity in the etiopathogenesis of SASP allergy and of dose-independent drug-induced pancreatitis.

Respective roles of hypoxia and halothane metabolism in halothane-induced liver injury in rats

To evaluate the respective roles of halothane metabolism and hypoxia in rats with halothane hepatotoxicity, experiments were designed with special reference to blood gas. After pretreatment with phenobarbital (80 mg per kg., i.p.) for four consecutive days, rats were exposed to 1.0% halothane under a mildly hypoxic condition (FiO2 = 14%) for 2 hr. Since halothane anesthesia caused significant decrease in PaO2 levels, rats exposed to a highly hypoxic atmosphere (FiO2 = 10%) in which PaO2 levels were comparable to those in the halothane group, served as the control. In the halothane group, marked centrilobular necrosis and elevation of SGPT activity were observed; neither significant histological lesions nor elevation of transaminase activity occurred in the highly hypoxic group. Although phenobarbital treatment did not decrease PaO2 levels during halothane anesthesia, the serum fluoride level, which appears to reflect quantitatively the reductive pathway of halothane metabolism, increased. These results strongly indicate that halothane metabolism rather than hypoxia, per se, plays a major role in development of halothane-induced liver injury in rats.

Purification of haptoglobin and its effects on lymphocyte and alveolar macrophage responses

Clinical observations made on a patient with acute hypersensitivity pneumonitis revealed that the patient's serum contained a mitogenic inhibitor and an extremely high haptoglobin (Hp) level; this led to an investigation of the role of Hp in lymphocyte function. Hp was isolated and purified from acute phase rabbit serum by a new method using DE-52 anion exchange chromatography and preparative isoelectric focusing in a range of pH 3.0-5.0. This technique produced a homogenous, biologically active product in fewer steps and in higher yields than existing techniques. Purified rabbit Hp significantly inhibited polyclonal lymphocyte mitogenic responses to PHA or Con A in a dose-response fashion. Hp also significantly inhibited B-cell mitogenesis at a high concentration (200 mg/100 ml) in response to LPS while it enhanced B-cell mitogenesis at lower concentrations (50 and 100 mg/100 ml). Purified Hp had no effect on monoclonal, antigen-specific (BSA) mitogenesis. Rabbit alveolar macrophages produced significant amounts of prostaglandin E in vitro in response to LPS but Hp had no effect on this production. However, Hp alone caused approximately the same amount of stimulation of PGE production by alveolar macrophages as did LPS alone. The ability of Hp to modulate lymphocyte as well as macrophage function seems to indicate that Hp plays a role in the moderation of inflammation. This ability to moderate inflammation, especially in the lungs, may play an important role in regulating tissue damage and disease following inhalation of inflammatory aerosols.

Potentiation of halothane hepatotoxicity by chronic ethanol administration in rat: an animal model of halothane hepatitis

To determine if chronic ethanol administration modifies the effect of halothane on the liver, fourteen male Wistar rats were pair-fed nutritionally adequate liquid diets containing either ethanol (36% of calories) or isocaloric carbohydrate (controls) for 6 weeks. After halothane anesthesia of these animals under different oxygen concentration, the livers were examined light microscopically as well as biochemically. The livers from rats fed ethanol which received halothane at low oxygen concentration showed multifocal or patchy necrosis primarily in the centrilobular regions with parenchymal lipid accumulation, whereas no such lesions were not observed in pair-fed controls. Hepatic necrosis was also seen after halothane anesthesia even at ambient oxygen concentrations, although the degree of necrosis was much milder. Hepatic microsomal cytochrome P450 content was increased by 30% after ethanol but was decreased following halothane anesthesia. These data suggest that halothane is hepatotoxic to liver of rats chronically pretreated with ethanol, especially under hypoxic condition.

Partial purification of the cholestatic factor derived from the lymphocytes of tuberculin-sensitized guinea pigs

When lymph node lymphocytes from the tuberculin-sensitized guinea pigs were stimulated in vitro with PPD (purified protein derivatives) and the culture fluid was injected into the mesenteric vein of rats, a marked reduction of bile flow was observed. These culture supernatants contained cholestatic activity were fractionated by gel filtration using a Sephadex G-75 column followed by DEAE-cellulose column chromatography. Both the cholestatic activity and the macrophage migration inhibitory factor (MIF) activity were detected predominantly in the fourth fraction of gel filtration. By further fractionation using a DEAE-cellulose column chromatography, the cholestatic activity was separated into two fractions; one of them was shown to have both cholestatic activity and MIF activity, but the other did not have any detectable MIF activity. These results suggest that the cholestatic factor may be different at least partially from the MIF.

Immunological studies on the drug-induced allergic hepatitis

The possible involvement of cell-mediated immunity in the pathogenesis of drug-induced allergic hepatitis was investigated in 21 patients; 6 patients with cholestasis, two cases with the hepatitis resembling viral hepatitis and 13 cholestatic hepatitis. The peripheral blood lymphocytes from all these patients showed the positive lymphocyte transformation and MIF production when stimulated by the offending drug in the presence of liver specific lipoprotein. By injection of the culture medium prepared from activated lymphocytes into mesenteric vein of rat, a marked reduction of bile flow and bile acid secretion was observed in 12 cases among 17 patients tested. Active material which caused the reduction of bile flow was fractionated by a gel filtration and was identified to have similar molecular size to MIF. Morphologically, a dilated bile canaliculus with diminution of microvilli and vesicles around the dilated bile canaliculus were observed by an electron microscopy after injection of culture supernatant or their fractionated material into mesenteric vein of rat. No such changes could be seen in rats by administering the supernatant of lymphocytes from normal individuals prepared as above. Macrophage activating factor (MAF), a kind of lymphokines, was also detected in the culture medium of activated lymphocytes from seven patients among eight cases tested. The MAF-activated macrophages were shown to exhibit a cytotoxic effect on the separated liver cells by judging from the inhibition of albumin biosynthesis. Moreover, the antibody-dependent cell-mediated cytotoxic reaction as well as lymphocyte-mediated cytotoxicity were also demonstrated in three cases among nine patients tested. These observations suggest that diverse immune reactions were possible correlated to the pathogenesis of the drug-induced allergic hepatitis although their exact participation or relative significances are remained to be elucidated.

Halothane-induced nephrotoxicity

Two cases are reported of combined renal and hepatic failure following exposure to halothane anesthesia. Both patients presented with postoperative fever and rapidly deteriorating liver and kidney function. Both required peritoneal dialysis. Both patients died, and in both cases this was the second exposure to halothane. The pathologic features of the 2 cases were similar in that the liver changes were typical of those seen with halothane hepatitis and the renal lesion was similar to that of methoxyflurane nephritis. This is, to our knowledge, the third report of renal failure occurring after halothane anesthesia. Possible mechanisms regarding its toxicity are discussed.

[Immunosuppressive and cytotoxic effect of the humoral factors from ischemic damaged organs (author's transl)]

These studies demonstrate the presence of an immunosuppressive and cytotoxic factor in the perfusate of ischemic damaged liver. A BDE rat liver perfusate (LP) was prepared after 6 h warm ischemia by intraportal perfusion with 2 ml/g of Ringer's solution (one time-LP1 or five times-LP5 with the same volume of solution). Protein amount of LP1 and LP5 was 0.9 and 2.8-3.9 mg/ml. In vivo activity of the hepatic perfusates was studied by effect on renal allograft survival time. LEW rats with BDE kidney transplant, treated daily with 2 ml of LP1 for 5 days, starting on the day of grafting, survived 8.9 +/- 1.8 days, significantly longer than control animals (6.5 +/- 0.5 days). After administration of LP5 renal recipients survived 10.3 +/- 1.3 days and when the treatment with LP5 was prolonged to 10 days animals survived 9-34 days (mean 15.3 +/- 7.3 days). The presence of the suppressive factor was also studied in renal, spleen and heart extracts, prepared after 6 h warm ischemia. Protein amount of extracts was adjusted to 3-4 mg/ml by Ringer's solution. Immunosuppressive activity of LP and other organ extracts was tested in vitro by their influence on MLC reaction (LEW and BDE lymphocytes) and on LEW cells in the PHA stimulation assay. Lymphocyte blastogenic response on MLC reaction and in culture with PHA was strongly inhibited by LP but weakly by organ extracts. Hepatic perfusates were cytotoxic against lymphocytes and fibroblasts in a three day cultures. Cytotoxic activity of the organ extracts was lower than LP. Extract of the cold preserved kidneys showed immunosuppressive and cytotoxic effect like extract of ischemically injured kidneys but smaller than LP. After heat inactivation at 70 degrees C the activity of hepatic perfusate decreased. Immunosuppressive organ factor (IOF) seems to be a normal cell component, not a decomposition product of the ischemically damaged hepatic tissue.

Immunological studies on drug-induced allergic hepatitis--hepatocellular injury by macrophage-mediated cytotoxicity

When the peripheral blood lymphocytes from patients with drug-induced allergic hepatitis were stimulated with a specific drug in vitro in the presence of a liver cytosol fraction containing liver specific antigen, lymphocyte transformation was seen in eight out of 11 patients. The macrophage activating factor (MAF), a kind of lymphokines, was also detectable in the culture medium of activated lymphocytes from seven out of eight patients who showed positive blastogenesis evaluated the uptake of 3H-glucosamine into macrophages. MAF-activated macrophages exhibited a cytotoxic effect on separated liver cells resulting in a marked inhibition of albumin synthesis. This macrophage-mediated cytotoxicity was also observed in eight out of 11 patients who showed positive lymphocyte transformation. These observations suggest that macrophage-mediated cytotoxicity may play some role in the pathogenesis of drug-induced allergic hepatitis.

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

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

Peripheral lymphocyte culture in the diagnosis of drug induced liver injury

In order to evaluate the usefulness of the peripheral lymphocyte culture method for the diagnosis of drug-induced liver injury, a study was carried out on 21 cases of drug-induced liver injury (Group A). Nine cases in Group A showed a positive lymphocyte stimulation test. Out of 9 cases which showed positive stimulation six cases were cholestatic type of liver injury, and the remaining three were of hepatitic type. The results suggest that peripheral lymphocyte culture method is a useful method for diagnosis of drug-induced liver injury.

Late onset chronic mucocutaneous candidiasis with lymphoma and specific serum inhibitory factor

A patient with late onset chronic mucocutaneous candidiasis developed lymphocytic lymphoma. A specific inhibitor of in vitro lymphoproliferative responses to candidal antigen was detected in her serum which persisted following clinical remission of candidiasis after combined amphotericin-B and 5-Fluorocystosine therapy. It is unclear whether the combined therapy was exclusively anticandidal, nonspecific immunostimulant or cytotoxic affecting the underlying incipient lymphoma.

Leukocyte migration inhibition induced by the combination of drug and a liver constituent in patients with drug-induced hepatitis

The leukocyte migration inhibition test in agarose medium was performed in 23 cases of clinically diagnosed drug-induced hepatitis. When the test antigen was the combination of soluble phase of a liver homogenate fractionated by Sephadex G-100 which should have contained liver specific antigen and the offending drug the leukocyte migration was inhibited in 86% of cases. Whereas none of 12 cases of drug allergy without hepatic injury showed a positive result with the same combination of antigens. Other organ homogenate-muscle and kidney-never gave positive results when mixed with the offending drugs in cases of drug-induced hepatitis. It was concluded that in hypersensitivity type drug-induced hepatitis cell-mediated immunity might be established to the complex of liver specific antigen and the drug.