Quinine-induced granulomatous hepatitis.

Many adverse reactions to quinine have been reported. A 65 year old woman taking quinine sulphate for nocturnal leg cramps presented for investigation of episodes of malaise, fever, nausea, vomiting, and polyarthralgia. Granulomatous hepatitis was diagnosed, for which no common cause was found. She was challenged with quinine sulphate; within hours her temperature had risen and her symptoms returned; transaminase activities rose within 48 hours, as did erythrocyte sedimentation rate. After withdrawal of the drug symptoms abated and transaminase activities returned to normal. The biochemical response to challenge with quinine implicates the drug as the cause of the liver disturbances. Quinine should be added to the list of drugs known to cause granulomatous hepatitis and should be considered in cases where symptoms are episodic or where no other cause is apparent.     

D-penicillamine-induced granulomatous hepatitis in brown Norway rats

The mechanism of idiosyncratic drug reactions (IDRs) remains poorly understood. D-penicillamine treatment is associated with a wide range of autoimmune reactions including liver injury. An animal model which utilizes brown Norway (BN) rats has been used to investigate the mechanism of D-penicillamine-induced IDRs because it mimics the autoimmune reactions that occur in humans. The purpose of this study was to investigate the type of liver injury that results from D-penicillamine treatment in BN rats. We had previously noted that D-penicillamine caused histological changes in the liver, but there was no increase in alanine transaminase (ALT), and we assumed that there was no significant injury. However, we subsequently discovered that D-penicillamine inhibits the ALT assay. In the present study, we found that treatment of BN rats with a low doses of D-penicillamine (10 or 15 mg/day) resulted in a mild increases in glutamate dehydrogenase (GLDH) and sorbitol dehydrogenase (SDH) activities; however, this was not associated with histological changes. A higher dose of D-penicillamine (20 mg/day) resulted in 63 % of the rats developing a skin rash, and these rats had elevated serum GLDH and SDH levels with histopathological changes characteristic of granulomatous hepatitis. This included large clusters of leukocytes in the form of granulomas that contained neutrophils, macrophages, and CD8 T cells. These changes did not occur in the rats that did not get sick. This model may be a good model to investigate the characteristics of drug-induced granulomatous hepatitis.     

Immunopathology of alkaline phosphataseinduced granulomatous hepatitis in rats

Granulomatous inflammation is a specific type of chronic inflammation in which macrophages and T-cell-mediated immunity to the inciting agent play a pivotal role. In the present study, granulomatous hepatitis was induced in rats by the administration of a single intravenous dose of porcine intestinal alkaline phosphatase. The cellular composition of the hepatic granulomas was analyzed in-situ with a number of recently developed mouse anti-rat monoclonal antibodies to cells of the monocyte-macrophage lineage and lymphocyte subsets. Well-developed granulomas consisted of aggregates of macrophages with central modification into epithelioid cells, a peripheral rim of T- and B-lymphoid cells, including considerable numbers of immunoblasts and plasma cells. In addition, the periphery of the granulomas contained many fat storing cells, a sinusoidal cell type thought to play a central role in hepatic fibrosis. Moreover, intense immunostaining for the extracellular matrix proteins fibronectin and collagen type III was observed at the periphery of the lesions. The granulomas persisted for long periods without eliciting liver cirrhosis. Alkaline phosphatase induced hepatic granulomas in the rat may help to elucidate the contribution of cells of the B-lineage to chronic granulomatous inflammation.     

Hypersensitivity vasculitis induced by cefoperazone/sulbactam

Background

Cefoperazone has not been reported to cause vasculitic complications before. Here, we report a case of hypersensitivity vasculitis associated with cefoperazone/sulbactam.

Case presentation

A 13-year-old girl with appendicitis developed hypersensitivity vasculitis on the fifth day of cefoperazone/sulbactam therapy. Hypersensitivity vasculitis resolved gradually after removal of the agent on the seventh day and did not recur. Although hypersensitivity vasculitis has multiple causes, coexistence of hypersensitivity vasculitis and cefoperazone treatment, and the quite resolution of the disease after removal of the drug, strongly favours a causative relationship.

Conclusion

To our knowledge, this is the first report of a hypersensitivity vasculitis associated with cefoperazone.