Co-amoxiclav jaundice: clinical and histological features and HLA class II association

BACKGROUND AND AIMS

Jaundice associated with co-amoxiclav has been increasingly recognised. We aimed to characterise its clinical and histological features and to investigate linkage with human leucocyte antigen class II haplotypes.

METHODS

We identified cases in the west of Scotland in the period 1991-1997 and performed polymerase chain reaction amplification and oligonucleotide probing on whole blood.

RESULTS

Twenty two cases were identified (10 male, mean age 59.1 years). Jaundice occurred a median of 17 days after drug commencement, with a median peak bilirubin level of 225 micromol/l (range 84-598) and median duration of jaundice 69 days (range 29-150). Two patients had primary biliary cirrhosis and two other patients had persistently abnormal liver biochemistry on follow up. One death occurred in a frail elderly woman despite resolving jaundice. The frequency of jaundice was 1 in 78 209 co-amoxiclav prescriptions. Liver biopsy, available in 12 patients, showed perivenular bilirubinostasis, accompanying reactive ceroid laden macrophages, and portal inflammation with focal injury to interlobular bile ducts. Fourteen of 20 patients had DRB1*1501 compared with 27 of 134 controls (p<2.5 x 10(-6); odds ratio (OR) 9.25; relative risk (RR) 6.43). Of these, seven patients were homozygous for DRB1*1501(p< 10(-8); OR 35.54; RR=8.68) compared with two of 134 controls. All patients with DRB1*1501 had the extended haplotype DRB1*1501-DRB5*0101-DQA1*0102-DQB1*0602. There were no clinical or histological differences between genotypes.

CONCLUSIONS

Co-amoxiclav associated hepatotoxicity may have a genetic basis and be delayed, severe, and prolonged, although complete recovery is usual.

Forced expression of murine IL-17E induces growth retardation, jaundice, a Th2-biased response, and multiorgan inflammation in mice

IL-17 is a proinflammatory cytokine, and its in vivo expression induces neutrophilia in mice. IL-17E is a recently described member of an emerging family of IL-17-related cytokines. IL-17E has been shown to bind IL-17Rh1, a protein distantly related to the IL-17R, suggesting that IL-17E probably possesses unique biological functions. In this study, we have identified the murine ortholog of IL-17E and developed transgenic mice to characterize its actions in vivo. Biological consequences of overexpression of murine (m)IL-17E, both unique to IL-17E and similar to IL-17, were revealed. Exposure to mIL-17E resulted in a Th2-biased response, characterized by eosinophilia, increased serum IgE and IgG1, and a Th2 cytokine profile including elevated serum levels of IL-13 and IL-5 and elevated gene expression of IL-4, IL-5, IL-10, and IL-13 was observed in many tissues. Increased gene expression of IFN-gamma in several tissues and elevated serum TNF-alpha were also noted. In addition, IL-17E induces G-CSF production in vitro and mIL-17E-transgenic mice had increased serum G-CSF and exhibit neutrophilia, a property shared by IL-17. Moreover, exposure to mIL-17E elicited pathological changes in multiple tissues, particularly liver, heart, and lungs, characterized by mixed inflammatory cell infiltration, epithelial hyperplasia, and hypertrophy. Taken together, these findings suggest that IL-17E is a unique pleiotropic cytokine and may be an important mediator of inflammatory and immune responses.

Evaluation of CA 19-9 as a serum tumour marker in pancreatic cancer

Serum concentrations of the CA 19-9 antigen were determined in 91 patients with pancreatic cancer and in 111 patients with benign pancreatic, biliary and hepatocellular diseases. The CA 19-9 concentration was above the cut-off limit (37 U ml-1) in 78% of the patients with pancreatic cancer and high levels (greater than 500 U ml-1) were seen in 56% of these patients. Elevated levels were also seen in benign diseases (22%), especially in patients with extrahepatic cholestasis (up to 440 U ml-1). Hepatocellular jaundice and pancreatitis were associated with normal values (84% of the patients), or with only slightly elevated CA 19-9 levels (up to 88 U ml-1). The CA 19-9 test can be useful as an additional diagnostic tool for the detection of pancreatic cancer. Preliminary results suggest that the CA 19-9 assay can be used in the monitoring of surgically treated patients.

A vigorous virus-specific CD4+ T cell response may contribute to the association of HLA-DR13 with viral clearance in hepatitis B

A strong virus-specific CD4+ and CD8+ T lymphocyte response to hepatitis B virus (HBV) has been associated with viral clearance, but little is known about factors determining the individual's ability to mount such a T cell response. Recently a strong association between the HLA class II allele DR13 and a self-limited course of HBV infection has been described. In the present study of 33 patients with acute hepatitis B we show that individuals carrying HLA-DR13 mount a more vigorous CD4+ T cell response to HBV core (5706 ct/min (25th/75th percentile 3239 ct/min; 10,552 ct/min)) than patients without HLA-DR 13 (1365 ct/min (490 ct/min; 5334 ct/min); P = 0.006). However, peptide epitopes aa 50-69, aa 61-85, and aa 81-105 were recognized most frequently by both patient groups. Moreover, among 14 HBV core-specific CD4+ T cell clones from two patients with HLA-DR13, only one T cell clone was HLA-DR13-restricted. Our data suggest that the beneficial effect of the HLA-DR13 alleles on the outcome of HBV infection could be explained by a more vigorous HBV core-specific CD4+ T cell response, which may either be due to more proficient antigen presentation by the HLA-DR13 molecules themselves or a linked polymorphism in a neighbouring immunoregulatory gene.

Serum CA 50 as a tumor marker in pancreatic cancer: a comparison with CA 19-9

CA 50 is a new tumor marker based on a monoclonal antibody (MAb) against a human colorectal carcinoma cell line. The CA 50 antigen is similar, but not identical, to the tumor marker CA 19-9. The serum concentrations of CA 50 were measured by an immunoradiometric assay (CA 50 IRMA) in 95 patients with pancreatic cancer and in 94 patients with benign pancreatic, biliary and hepatocellular diseases. The CA 50 concentration was above the cut-off limit of 17 U/ml in 71% of the patients with pancreatic cancer. Elevated CA 50 levels were also seen in 29% of the patients with benign diseases (up to 250 U/ml), especially in patients with extra-hepatic cholestasis (34%) and hepatocellular jaundice (46%). The results of the immunoradiometric assay were compared to those of the commercially available CA 50 RIA inhibition test. The sensitivities of the two CA 50 assays for pancreatic cancer were similar, but the specificity of the IRMA assay was higher. The CA 50 and CA 19-9 values showed a strong positive correlation and the assay parameters of the tests were almost similar. CA 50 seems a promising tumor marker in the detection and follow-up of patients with pancreatic cancer.

Unconjugated bilirubin inhibits in vitro cytotoxic T lymphocyte activity of human lymphocytes

Septic complications have been major problems in the management of patients with obstructive jaundice and neonatal jaundice. This study investigates effects bilirubin on human T lymphocyte responses against allogeneic mixed lymphocyte reaction. In vitro exposure of human peripheral blood mononuclear cells (PBMNC) with unconjugated bilirubin at pathological levels (6 to 12 mg/dl) did not alter the subsets of CD3, CD4, CD8, CD14, CD19 and CD56 positive populations, or expression of costimulatory surface molecules CD2, CD3, CD4 and CD8. Further incubation of bilirubin-treated PBMNC with irradiated B lymphoid Raji cells after removal of the extracellular bilirubin resulted in a dose-dependent decrease of cytotoxic T lymphocyte (CTL) activity, DNA synthesis, and expression of Tac antigen (CD25) and transferrin receptor (CD71). However, no significant change of interleukin-2 (IL-2) production was observed after this incubation between bilirubin-treated and -untreated PBMNC. These results suggest that bilirubin inhibits the induction of CTL activity, and this defect may result from the impaired responsiveness against IL-2. These observations may help explain the increased infection observed in hyperbilirubinemic patients.

Infection with hepatitis A and B viruses in French volunteers working in tropical Africa

The risks of developing hepatitis A and B virus infections were studied in 233 French volunteers working for 18 to 35 months in the field in West and Central Africa. During their stay in Africa, the seroconversion rates to antibody to hepatitis A virus of the immunoglobulin G (IgG) class and hepatitis B marker(s) were 48.1% and 10.5%, respectively; 21.5% of the volunteers developed jaundice, and 78.0% of the jaundice cases were associated with hepatitis A seroconversion, 14.0% with hepatitis B seroconversion, 4.0% with seroconversion to both, and 4.0% without seroconversion. Male health workers were at lower risk than other male occupations for hepatitis A infection. Female health workers were at higher risk than other female occupations for hepatitis A infection. Health workers were at a lower risk of hepatitis B infection, but the significance was borderline. Populations such as these volunteers should receive immunoprophylaxis against hepatitis A and B infections.

Anergy in jaundiced patients

A prospective study of delayed hypersensitivity was carried out in jaundiced patients. One hundred and nineteen subjects were studied. Fifty-nine were controls and sixty were patients with pancreatobiliary pathology and biliary tract obstruction. A Multitest technique was used to evaluate the delayed hypersensitivity response, classifying the subject into one of three groups: immunocompetent, relatively anergic and anergic. In the control group, 76 per cent of the subjects were immunocompetent as opposed to 17 per cent of the patients (P less than 0.001). Ten per cent of the control subjects and fifty-five per cent of the patients presented anergy (P less than 0.001). Amongst the patients no difference could be found in the index of anergy between malignant or benign pathology. A greater incidence of postoperative septic complications in anergic and relatively anergic patients was found. Our study indicates a relationship between jaundice and anergy.

Auto-anti-Pra: a 'second' example in a newborn

A second example of anti-Pra was recognized in a newborn infant which exhibited several signs of development disease. The antibody was complement-fixing 19S IgM and showed a high thermal range but no detectable haemolytic anaemia was associated. It gave negative reactions with a panel of animal cells as well as with two samples of human En(a-) cells. The latter, however, could absorb the antibody.

Treatment of unresectable extrahepatic cholangiocarcinoma using hematoporphyrin photodynamic therapy: A prospective study

BACKGROUND

The available evidence of Photodynamic therapy (PDT) combined with stent placement treatment for unresectable extrahepatic cholangiocarcinoma (EHCC) is still insufficient. It also remains unclear whether PDT influences systemic inflammatory response.

AIM

To explore the clinical efficacy and safety of the combination treatment and the systemic inflammatory response in patients with EHCC.

METHODS

Patients with unresectable EHCC underwent either the combined treatment using Hematoporphyrin PDT and stent placement (PDT+stent group, n=12) or stent-only (stent group, n=27). The primary end-point was overall survival. Tumor necrosis factor (TNF)-α and interleukin (IL)-6 levels were measured. Quality of life was assessed using the Karnofsky performance scale (KPS) every 3 months.

RESULTS

Average survival time (13.8 vs. 9.6 months), and 6-month (91.7% vs. 74.1%), and 1-year (58.3% vs. 3.7%) survival rates of PDT+stent group were significantly increased compared with the stent group. KPS scores in the PDT+stent group were significantly improved. TNF-α and IL-6 levels were significantly increased in the PDT+stent group.

CONCLUSION

Hematoporphyrin-PDT combined with stent placement is an effective and safe treatment for EHCC. The treatment might promote systemic inflammatory response.

A comparison of different methods of screening blood donations for HBsAg

In a retrospective comparison between countermigration immunoelectrophoresis (CIEP) and reverse passive haemagglutination (RPHA) for screening 260,500 blood donations, the latter's 10-fold increase in sensitivity resulted in 36% more HBsAg detections. In a prospective comparison between RPHA and radioimmunoassay (RIA) the latter's 40-fold increase in sensitivity over RPHA resulted in 11% more detections than RPHA in 27,094 new donors. One in 500 new donors was HBsAg-positive by RPHA, compared with 1 in 11,000 established donors who had donated and been tested previously. Acute hepatitis B infections, though uncommon, accounted for a greater proportion of the HBsAg-positive found in "established" rather than new donors. Reported post-transfusion hepatitis cases have declined following the introduction of screening tests in 1971. The feasibility of RIA testing at a transfusion centre supplied simply with the two basic RIA reagents has been demonstrated.

Type C-chronic hepatitis patients who had autoimmune phenomenon and developed jaundice during interferon therapy

Of a total of 2342 patients with type-C chronic hepatitis treated with interferon (IFN) at this hospital, 3 patients developed jaundice during the course of IFN therapy, but all 3 of them exhibited negative conversion of hepatitis C virus (HCV)-RNA following readministration of IFN. All 3 patients were assessed as having "probable autoimmune hepatitis (AIH)" in accordance with the AIH scoring system, indicating association with an "autoimmune phenomenon". Readministration of IFN at a low-dose induced activation of the autoimmune phenomenon, leading to fulminant hepatocellular impairment. As a result, HCV-RNA content dropped dramatically, possibly contributing to the negative conversion of HCV-RNA noted following the readministration of IFN. At present, no adequate therapy has been established for type-C chronic hepatitis with autoimmune manifestations. However, in conclusion, our findings suggested that: IFN should be a frontline regiment: (1). if autoantibody titers are low or patients are rated as having "probable AIH" or lower in accordance with the AIH scoring system, indicating a strong link to chronic hepatitis or (2). if IFN is expected to be efficacious on the basis of genotype of HCV-RNA level; even if there is acute exacerbation of type-C chronic hepatitis, IFN should be re-administered in the HCV-RNA level has dropped subsequently.

Liver injury induced by a Japanese herbal medicine, sairei-to (TJ-114, Bupleurum and Hoelen Combination, Chai-Ling-Tang) R1

The case is reported of a man who showed acute hepatitis with jaundice after he was given a Japanese herbal medicine, sairei-to (TJ-114, Bupleurum and Hoelen Combination, Chai-Ling-Tang). Unusually, the component thought to be responsible for the observed drug-induced liver injury was able to be identified. Lymphocyte migration inhibition testing indicated that the tuber of the perennial herbage Pinellia ternate was the causative agent.

Acute jaundice in Vientiane, Lao People's Democratic Republic

Analysis of serum samples from patients with acute jaundice by means of enzyme-linked immunosorbent assay and polymerase chain reaction testing provided the first profile of this condition in Vientiane, Lao PDR, in 1995 and 1996. In a case-control, hospital-based study, evidence of acute infections due to hepatitis A and B viruses was found in 14% and 10% of cases, respectively. Hepatitis E virus, however, did not appear to contribute to clinically recognized acute jaundice. Similarly, antibody to hepatitis C virus was recognized in almost equal proportions of cases (8%) and controls (6%), thus representing probable background infections. The detection of hepatitis G virus marks the first report of this virus in Lao PDR. The large proportion (21%) of new leptospiral infections in cases without acute hepatitis A or B was notable. This finding suggests significant regional underreporting of leptospirosis as a cause of acute jaundice. The limited laboratory diagnostic capabilities for confirming a differential diagnosis of leptospirosis contribute to the lack of attention paid to this important health problem.

Receiver operating characteristic (ROC) curve analysis of the tumour markers CEA, CA 50 and CA 242 in pancreatic cancer; results from a prospective study

The serum values of the tumour markers carcinoembryonic antigen (CEA), cancer-associated carboanhydrate antigens CA 50 and CA 242 were evaluated in 193 patients with hepatopancreato-biliary diseases by receiver operating characteristic (ROC) curve analysis in order to compare their diagnostic accuracy in pancreatic cancer (n = 26), and to define optimal cut-off levels for the serum values of these tumour markers in the diagnosis of pancreatic cancer. The ROC analysis showed that all marker tests are considerably sensitive (77-81%) at the specificity level of 80%. The CA 242 test was more sensitive than CEA and CA 50 at high specificity levels (> 0.90) but slightly less sensitive at low specificity levels (< 0.60). The CEA test and CA 50 test performed equally well at high and low specificity levels. According to this study, it would seem optimal to use the cut-off level of 4.1 ng ml-1 for CEA, and the level of 137 U ml-1 for CA 50, since they gave a sensitivity of 77% at the specificity levels of 83% and 84%, respectively. For CA 242 the optimal cut-off level was 21 U ml-1, which gave a sensitivity and specificity of 81%. In conclusion, the results of ROC curve analysis suggest that the CA 242 test has an advantage over CEA and CA 50 because of its higher specificity in pancreatic cancer. In addition, it would seem reasonable to use higher cut-off values than what has been recommended for CEA and CA 50 in the diagnosis of pancreatic cancer, but for CA 242 the recommended cut-off level of 20 U ml-1 seems appropriate.

Jaundice associated with nonhepatic Staphylococcus aureus infection. Does teichoic acid have a role in pathogenesis?

A previously healthy young man developed jaundice early in the course of a febrile illness caused by an unrecognized deep-seated Staphylococcus aureus abscess. The serum bilirubin level peaked 11 days before the abscess was discovered and drained. During this time the bilirubin level returned to normal, circulating immune complexes were detected, and the serum free teichoic acid antibody titer was elevated. Indirect immunofluorescent staining of liver tissue for teichoic acid revealed 2+ nuclear fluorescence of the hepatocytes. These findings suggested that circulating free teichoic acid was deposited in the liver and may have had an endotoxin-like effect in the hepatocytes. With the appearance of specific antibody in the serum, circulating teichoic acid was neutralized and further hepatic injury ceased.

Hepatitis in a Family Infected by Chlamydia Psittaci

Hepatic involvement is considered a rare complication of psittacosis. Occurrence of icteric hepatitis as the cardinal manifestation of the disease has been rarely reported. We describe two members of a family infected by psittacosis, in whom icteric hepatitis was the prominent expression of the disease.

The diagnosis of psittacosis was confirmed by isolation of the pathogen and by detection of serum antibodies to Chlamydia species. No serological evidence for acute TWAR infection was found. Chlamydia psittaci was also isolated from the family's parrot.