[Undesired drug effects after taking chlormezanone (Muscle Trancopal) with lethal results]

HISTORY AND CLINICAL FINDINGS

A 34-year-old woman was admitted for treatment of toxic epidermolysis of the skin and mucosa. 16 days previously she had started to take chlormezanone (Muskel Trancopal) and some other medications for pain in the shoulder and neck. On admission she had a fever of 39 degrees C and, in addition to the epidermolysis, diffuse abdominal pain on pressure and blood-streaked stool.

INVESTIGATIONS

Liver enzyme activities (GOT 979 U/I, GPT 1496 U/I, gamma GT 201 U/I) alkaline phosphatase 515 U/I), bilirubin (3.9 mg/dl) and pancreatic enzyme activities were raised. Sonography was nondiagnostic, computed tomography demonstrated only a small amount of ascites.

TREATMENT AND COURSE

The epidermolytic lesions, cholestatic hepatitis and pancreatitis markedly regressed under aseptic wound treatment, antibiotics and parenteral nutrition. Persistent blood-streaked stools and bilateral pneumonia with progressive respiratory failure developed. Despite intensive medical care the patient died after 14 days from protracted sepsis with multi-organ failure. Autopsy additionally revealed adult respiratory distress syndrome and complete loss of colonic mucosa.

CONCLUSION

The severe course of a toxic epidermal necrosis with fatal outcome is the first such case reported in Germany that very probably was caused by chlormezanone. 4 weeks after this case was reported to the German Doctors' Drug Commission, the manufacturers of the drug withdrew it from the market.

Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis

BACKGROUND

Toxic epidermal necrolysis and Stevens-Johnson syndrome are rare, life-threatening, drug-induced cutaneous reactions. We conducted a case-control study to quantify the risks associated with the use of specific drugs.

METHODS

Data were obtained through surveillance networks in France, Germany, Italy, and Portugal. Drug use before the onset of disease was compared in 245 people who were hospitalized because of toxic epidermal necrolysis or Stevens-Johnson syndrome and 1147 patients hospitalized for other reasons (controls). Crude relative risks were calculated and adjusted for confounding by multivariate methods when numbers were large enough.

RESULTS

Among drugs usually used for short periods, the risks were increased for trimethoprim-sulfamethoxazole and other sulfonamide antibiotics (crude relative risk, 172; 95 percent confidence interval, 75 to 396), chlormezanone (crude relative risk, 62; 21 to 188), aminopenicillins (multivariate relative risk, 6.7; 2.5 to 18), quinolones (multivariate relative risk, 10; 2.6 to 38), and cephalosporins (multivariate relative risk, 14; 3.2 to 59). For acetaminophen, the multivariate relative risk was 0.6 (95 percent confidence interval, 0.2 to 1.3) in France but 9.3 (3.9 to 22) in the other countries. Among drugs usually used for months or years, the increased risk was confined largely to the first two months of treatment, when crude relative risks were as follows: carbamazepine, 90 (95 percent confidence interval, 19 to infinity); phenobarbital, 45 (19 to 108); phenytoin, 53 (11 to infinity); valproic acid, 25 (4.3 to infinity); oxicam nonsteroidal antiinflammatory drugs (NSAIDs), 72 (25 to 209); allopurinol, 52 (16 to 167); and corticosteroids, 54 (23 to 124). For many drugs, including thiazide diuretics and oral hypoglycemic agents, there was no significant increase in risk.

CONCLUSIONS

The use of antibacterial sulfonamides, anticonvulsant agents, oxicam NSAIDs, allopurinol, chlormezanone, and corticosteroids is associated with large increases in the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. But for none of the drugs does the excess risk exceed five cases per million users per week.

Chlormezanone in primary fibromyalgia syndrome: a double blind placebo controlled study

Primary fibromyalgia syndrome (PFS) is a common condition that often proves resistant to health interventions. Chlormezanone combines corrective effects on disturbed sleep with muscle-relaxant properties, and therefore could be of potential benefit in PFS. Forty-two female patients with PFS (mean age 49, range 24-72 years) were randomly and blindly allocated either chlormezanone 400 mg nocte or placebo. Patients were assessed by single observer at 0, 3 and 6 weeks of treatment; assessments included sleep quality, inactivity and morning stiffness, morning alertness, tender point score, mood change and global opinion (patient and observer). No beneficial therapeutic effect could be attributed to chlormezanone. Although there are problems in assessing severity of a predominantly subjective condition, this essentially negative finding is of interest in respect to the pathogenesis of PFS.

Chlormezanone-induced fulminant hepatitis in a pregnant woman: successful delivery and liver transplantation

The case of a 29 year old woman affected by fulminant hepatitis during the third trimester of pregnancy, after a 3 week administration of chlormezanone is reported. Following induced Caesarean delivery, the patient underwent an orthotopic liver transplantation. The mother and her baby were in good condition 26 months after liver transplantation. In this case, chlormezanone was probably responsible for the fulminant hepatitis.

Drug-induced toxic epidermal necrolysis (Lyell syndrome) in patients infected with the human immunodeficiency virus

BACKGROUND

Although patients infected with the human immunodeficiency virus (HIV) are predisposed to cutaneous adverse drug reactions, only a few cases of toxic epidermal necrolysis (TEN) have been reported in this setting.

OBJECTIVE

Our purpose was to examine the features of TEN in HIV-infected patients.

METHODS

We performed a retrospective analysis of all HIV-infected patients in a series of 80 consecutive cases of TEN during a 6-year period.

RESULTS

Fourteen patients were HIV infected. They had typical TEN, with epidermal detachment involving 20.6% +/- 8.0% of the skin surface. Suspected drugs were sulfadiazine, trimethoprim-sulfamethoxazole, sulfadoxine, clindamycin, phenobarbital, and chlormezanone. Patients with the acquired immunodeficiency syndrome (AIDS) exhibit a dramatically increased risk of TEN. During our study period 15 cases of AIDS-associated TEN occurred in the greater Paris area, whereas 0.04 case would have been expected if the incidence of TEN were the same in these patients as in the general population.

CONCLUSION

HIV-infected patients, especially those with AIDS, may develop TEN that shares many similarities with the disease in immunocompetent patients.

Provocation tests in a chlormezanone-induced fixed drug eruption

Although as few as seven cases of fixed drug eruption (FDE) due to chlormezanone have been reported, it should not be overlooked as a cause of FDE. To identify the causative agent in FDEs, topical provocation tests are much safer and more convenient than systemic provocation tests. If results of topical provocation tests are reliable, they could become useful diagnostic as well as screening tests. Patch tests were performed in a suspected case of FDE due to chlormezanone on the patient's normal and prelesional skin with all ingested drugs whose concentrations were one and ten percent. The base was petrolatum. A positive reaction occurred only at the previously lesional site tested with chlormezanone, and was confirmed with oral provocation tests.

[Drug-induced hepatitis with cholestasis following therapy with chlormezanone]

The history of a 46 years old female patient is reported who suffered from rheumatoid arthritis. During therapy with chlormezanon and paracetamol symptoms of cholestatic liver disease developed. We believe that this was a side-effect of chlormezanon.

Fixed drug eruption due to a drug combination but not to its constituents

A fixed drug eruption due to a paracetamol-chlormezanone combination but not to either drug separately is described.

Hypnotics and hangovers: a pilot study of chlormezanone in general practice

Ten patients were included in this pilot study of chlormezanone, assessing its effects on duration and quantity of sleep and daytime performance using a pursuit rotor and a digit symbol test. Comparisons of the sleep assessments favoured chlormezanone, although the differences were not statistically significant. There was no evidence of any reduction in daytime performance after chlormezanone. The comparison of chlormezanone and placebo on the pursuit rotor test and the visual analogue assessment of hangover both slightly favoured the drug, but there were no significant differences. The study has demonstrated that it is feasible to evaluate hypnotic drugs more exactly in general practice.

Four-week tolerance study of chlormezanone for the treatment of insomnia in the elderly

A 4-week study of chlormezanone was carried out in thirty-two patients admitted to a geriatric ward and requiring regular night sedation. Two patients required 400 mg nightly, the remainder only 200 mg nightly. The duration and quality of sleep, and frequency of awaking refreshed, all improved during chlormezanone therapy. There was no deterioration in mental agility test performance. There were no serious side-effects, no significant changes in blood urea or liver function tests, and no evidence of drug accumulation. It is concluded that chlormezanone appears to be a well tolerated drug for elderly patients with sleep disturbance meriting further controlled evaluation.

[Gustatory disturbances as sideeffect of medical treatment (author's transl)]

A review of the pharmacological induced taste disorders is given. Many patients complain only of a spontaneous metallic, bitter or salty sensation in their mouths. More serious is the development of a dissociated hypogeusia or even an ageusia. 7 cases with gustatory disturbances caused by orally given medicine are presented. The phenylbutazone, oxyphedrine, carbamazepine, Muskel-Trancopal comp. (Chlormezanon, Paracetamol) and Lioresal (baclofen) were accused to have caused a partial or complete loss of taste. After the treatment had been discontinued it took weeks or even months for a complete recovery.