Unexplained hepatitis following halothane.

Full clinical and laboratory details of 203 patients with postoperative jaundice were submitted to a panel of hepatologists. All patients whose jaundice may have had an identifiable cause were excluded, which left 76 patients with unexplained hepatitis following halothane anaesthesia (UHFH). Hepatitis in 95% of these cases followed multiple exposure to halothane, with repeated exposure within four weeks in 55% of cases. Twenty-nine patients were obese, 52 were aged 41-70, and 53 were women. Thirteen patients died in acute hepatic failure. Rapid onset of jaundice after anaesthesia, male sex, and obesity in either sex were poor prognostic signs. Of the clinical stigmata of hypersensitivity, only eosinophilia was impressive. The UHFH group had a much greater incidence of liver kidney microsomal (LKM) and thyroid antibodies and autoimmune complement fixation than those patients whose jaundice related to identifiable factors. Thirteen of the 19 patients with LKM antibodies also had thyroid antibodies. In six patients retested two to three years later LKM antibodies had disappeared, although thyroid antibodies persisted. Rapidly repeated exposure to halothane may cause hepatitis, but such a complication is probably rare. Possibly obese women with a tendency to organ-specific autoimmunity may be more at risk. Nevertheless, the comparative risks of rapidly repeated halothane or non-halothane anaesthesia cannot be determined from the present data. If alternative satisfactory agents are available halothane should be avoided in patients with unexplained hepatitis after previous exposure, although in three to five patients with UHFH who were re-exposed to halothane jaundice did not recur.     

Halothane Hepatitis—A Preventable Disease?

Eleven patients with acute hepatitis following multiple anaesthetics with halothane have been seen at two hospitals during the last four years. Six had massive hepatic necrosis and died. Unexplained fever occurred in nine of the patients; two of these and one other had had previous episodes of jaundice after halothane anaesthesia. Thus, in ten patients the disease could have been avoided.     

Jaundice after repeated exposure to halothane: a further analysis of reports to the Committee on Safety of Medicines.

Aanalysis of data derived from 170 reports of jaundice developing after anaesthesia with halothane received after January 1974 confirmed the relations between multiple exposure to halothane and jaundice and between the number of exposures and the rapidity with which jaundice develops after exposure. When these reports were combined with 130 received earlier complete anaesthetic histories were available for 251 patients, 205 (82%) of whom had been exposed to halothane more than once; of these patients, 154 (75%) had been exposed more than once within 28 days. Altogether 139 (46%) of the 300 patients died.     

Jaundice after Repeated Exposure to Halothane: An Analysis of Reports to the Committee on Safety of Medicines

Analysis of data derived from 130 reports of jaundice occurring after anaesthesia with halothane showed a significant relation between the number of exposures to this anaesthetic and the rapidity with which jaundice develops after exposure. This is considered to provide strong evidence of a cause-effect relationship between the use of halothane and jaundice. Out of 114 patients with complete anaesthetic histories 94 (82%) had been exposed more than once; of those so exposed 80% had been anaesthetized with halothane more than once within 28 days. Altogether 66 (51%) of the 130 patients died.     

Experimental acute poisoning in mice induced by emestrin,a new mycotoxin isolated from Emericella species

The effects of emestrin (EMS), a secondary metabolite of the Emericella species, on male ICR mice were examined. The intraperitoneal LD₅₀ values of EMS were 17.7 and 13.0 mg/kg at 24 and 48 hr, respectively. The target organs of EMS were the heart, liver and thymus. In doses over 30 mg/kg the experimental animals died from cardiac failure shortly after the injections. Several survivors that were given EMS in doses under 20 mg/kg showed severe centrilobular necrosis in the liver at 24 hr. Marked degeneration of mitochondria was seen in electron micrographs of both cardiac muscle cells and hepatocytes. In the degenerated hepatocytes, prominent proliferation of RER, membrane-limited inclusions containing both ribosome-like granules and RER, and fenestrated lamella-like structures were observed. Massive necrosis of lymphocytes was always observed in the cortical layer of the thymus of the survivors within 24 hr, while bilateral adrenalectomized mice showed no discernible pathomorphological changes in the lymphoid tissues. Pretreatment of mice with diethyl maleate increased the incidence and severity of hepatic necrosis, whereas that with either cysteine or CoCl₂ reduced the severity of centrilobular necrosis of the liver. Pretreatment with phenobarbital had no significant effect on EMS-induced hepatic lesions.     

Naturally occurring Yersinia enterocolitica septicemia in patas monkeys (Erythrocebus patas)

Two cases of Yersinia enterocolitica septicemia occurred in a breeding group of 22 adult patas monkeys (Erythrocebus patas). Affected animals had acute clinical signs of depression, weakness, dehydration, hypothermia, hepatomegaly and pronounced leukopenia. Both animals died a few hours after treatment was initiated. Gross necropsy findings included jaundice, fluid in body cavities, hepatomegaly, splenomegaly, multiple white foci within the liver and spleen, generalized lymph node enlargement and numerous mucosal ulcerations in the colon. Primary histopathological lesions were multifocal hepatic necrosis, splenic necrosis, chronic ulcerative enteritis and diaphragmatic myositis with necrosis and edema. Yersinia enterocolitica was cultured from the liver, spleen, lung, jejunum and rectum. Wild rodents, particularly mice, may have been a source of infection for these animals, as the monkeys were housed in a rural, indoor-outdoor facility. A preliminary culture survey showed that some clinically normal patas monkeys harbored the organism in their intestinal tracts.     

Post-halothane Jaundice in Relation to Previous Administration of Halothane

The time interval since previous anaesthesia was compared in a surgical population in South Wales and in patients who developed jaundice after halothane. There was a significant difference in the pattern of time interval since previous general anaesthetics in the surgical population and in those patients who developed jaundice after halothane. In the group who developed jaundice there was an “excess” of patients who had had a previous halothane anaesthetic within four weeks. Halothane should if possible be avoided in patients who have had it before, particularly if this was within the previous four weeks. In the case of repeat halothane anaesthetics within four weeks, the risk seems to lie between 1 in 6,000 and 1 in 22,000.     

Onset of Postoperative Jaundice Related to Anaesthetic History

A review of 182 cases from the U.S. National Halothane Study showed the interval to the onset of jaundice after one exposure to halothane (91 cases) to be slightly shorter than the interval for those having had multiple exposures to the agent. These findings are in sharp contrast to other recently published results. Thirty-three cases of jaundice after the use of other anaesthetic agents are also reported.     

Halothane hepatitis in children.

It is often stated that halothane hepatitis in children is nonexistent or extremely rare. This syndrome occurred in seven children aged between 11 months and 15 years, one of whom, a 3 1/2 year old boy, died with fulminant hepatic failure. All the children had received multiple halothane anaesthetics (range 2-6, median 3). In all cases other causes of liver diseases were excluded, and in all but one the diagnosis was confirmed serologically by antibodies to halothane altered liver cell membrane antigens. These findings suggest that halothane hepatitis occurs in children, and the risk of halothane hepatitis should therefore be considered when choosing which agents to use in children who require multiple anaesthetics.     

Correlations between Clinical Features and Mortality in Patients with Vibrio vulnificus Infection

Vibrio vulnificus is a common gram-negative bacterium, which might cause morbidity and mortality in patients following consumption of seafood or exposure to seawater in Southeast China. We retrospectively analyzed clinical data of patients with laboratory confirmed V. vulnificus infection. Twenty one patients were divided into a survival group and a non-surviving (or death) group according to their clinical outcome. Clinical data and measurements were statistically analyzed. Four patients (19.05%) died and five patients gave positive cultures from bile fluid, and 16 other patients gave positive culture from blood or blisters. Ten patients (47.62%) had an underlying liver disease and marine-related events were found in sixteen patients (76.2%). Patients with heavy drinking habits might be at increased mortality (p = 0.028). Clinical manifestations of cellulitis (47.6%), septic shock (42.9%) and multiple organ failure (28.6%) were statistically significant when comparing survivors and non-survivors (p = 0.035, p = 0.021 and p = 0.003, respectively). The laboratory results, including hemoglobin < 9.0 g/L (p = 0.012), platelets < 2.0×10⁹ /L, prothrombin time activity (PTA) <20%, decreased serum creatinine and increased urea nitrogen were statistically significant (p = 0.012, p = 0.003, p = 0.028 and p = 0.028, respectively). Patients may be at a higher risk of mortality under situations where they have a history of habitual heavy alcoholic drink consumption (p = 0.028, OR = 22.5, 95%CI 1.5–335.3), accompanied with cellulitis, shock, multiple organ failure, and laboratory examinations that are complicated by decreased platelets, hemoglobin and significantly prolonged prothrombin time (PT).     

gamma-Carboxyglutamic acid content of hepatocellular carcinoma-associated des-gamma-carboxy prothrombin

Serum des-gamma-carboxy prothrombin (DCP) is a useful marker for the diagnosis of hepatocellular carcinoma (HCC), but the exact mechanism of its synthesis and its structural properties in liver diseases are unknown. DCP is measured by the monoclonal antibody MU-3. The purpose of this study was to examine the epitope of MU-3 and to characterize the differences in DCP between HCC and benign liver diseases. The epitope of MU-3 was examined by ELISA using prothrombin Gla domain polypeptides and was determined to be amino acid residues 17-27 of the prothrombin Gla domain, which has four gamma-carboxyglutamic acid residues (Gla) at positions 19, 20, 25 and 26. Peptides having a glutamic acid residue (Glu) at these positions reacted strongly to MU-3 but lost reactivity when Glu 19 or 20 was changed to Gla. In the order of gamma-carboxylation, MU-3 reacted strongly to DCP containing 0-1 Gla, weakly to 2-4 Gla and not at all to DCP containing more than five Gla. After adsorbing normal prothrombin with barium carbonate, DCP reaction to MU-3 was measured by determining the amount of DCP that was adsorbed by MU-3-coated beads. The proportion of DCP reacting to MU-3 in HCC was 41.0-76.8%, whereas in patients with benign liver diseases, only 0-42.1% reacted to MU-3. These results indicate that DCP variants preferentially synthesized in HCC have less than four Gla, which are restricted to positions 16, 25, 26 and 29, whereas DCP variants in benign liver diseases have more than five Gla.     

γ-Carboxyglutamic acid content of hepatocellular carcinoma-associated des-γ-carboxy prothrombin

Serum des-γ-carboxy prothrombin (DCP) is a useful marker for the diagnosis of hepatocellular carcinoma (HCC), but the exact mechanism of its synthesis and its structural properties in liver diseases are unknown. DCP is measured by the monoclonal antibody MU-3. The purpose of this study was to examine the epitope of MU-3 and to characterize the differences in DCP between HCC and benign liver diseases. The epitope of MU-3 was examined by ELISA using prothrombin Gla domain polypeptides and was determined to be amino acid residues 17–27 of the prothrombin Gla domain, which has four γ-carboxyglutamic acid residues (Gla) at positions 19, 20, 25 and 26. Peptides having a glutamic acid residue (Glu) at these positions reacted strongly to MU-3 but lost reactivity when Glu 19 or 20 was changed to Gla. In the order of γ-carboxylation, MU-3 reacted strongly to DCP containing 0–1 Gla, weakly to 2–4 Gla and not at all to DCP containing more than five Gla. After adsorbing normal prothrombin with barium carbonate, DCP reaction to MU-3 was measured by determining the amount of DCP that was adsorbed by MU-3-coated beads. The proportion of DCP reacting to MU-3 in HCC was 41.0–76.8%, whereas in patients with benign liver diseases, only 0–42.1% reacted to MU-3. These results indicate that DCP variants preferentially synthesized in HCC have less than four Gla, which are restricted to positions 16, 25, 26 and 29, whereas DCP variants in benign liver diseases have more than five Gla.     

Amebic abscess of the liver

In a review of the records in 50 cases of amebic abscess of the liver observed in the Canal Zone between 1920 and 1945 the following features were noted:Incidence was preponderantly in males and highest in persons between the ages of 20 and 40. None of the patients was under 21 years of age. There was a great variety of complaints at the time of admission to hospital. The most common was pain in the right upper quadrant of the abdomen. Demonstration of either elevated or fixed diaphragm by x-ray film and fluoroscopic examination was useful in diagnosis in a number of cases, but absence of such findings did not rule out abscess of the liver. In some cases there was history of previous dysentery with blood in the stools.One or another of three operative procedures was used for drainage of abscesses in 39 patients. Of the 39, six died; in five of the six, multiple abscesses were present. Emetine hydrochloride was given to all patients.     

AMEBIC ABSCESS OF THE LIVER

In a review of the records in 50 cases of amebic abscess of the liver observed in the Canal Zone between 1920 and 1945 the following features were noted:Incidence was preponderantly in males and highest in persons between the ages of 20 and 40. None of the patients was under 21 years of age.There was a great variety of complaints at the time of admission to hospital. The most common was pain in the right upper quadrant of the abdomen.Demonstration of either elevated or fixed diaphragm by x-ray film and fluoroscopic examination was useful in diagnosis in a number of cases, but absence of such findings did not rule out abscess of the liver.In some cases there was history of previous dysentery with blood in the stools.One or another of three operative procedures was used for drainage of abscesses in 39 patients. Of the 39, six died; in five of the six, multiple abscesses were present.Emetine hydrochloride was given to all patients.     

Bleeding time in patients with hepatic cirrhosis.

OBJECTIVE--To determine the frequency of an abnormal bleeding time in patients with cirrhosis and to relate this to known factors that affect primary haemostasis and to the severity of liver disease. DESIGN--Prospective clinical and laboratory study in patients admitted for complications or investigations of liver disease. SETTING--Royal Free Hospital hepatobiliary and liver transplantation unit. SUBJECTS--100 Consecutive inpatients aged 17-74 with various forms of cirrhosis, including alcoholic, biliary, autoimmune, viral, and cryptogenic. At least 10 days had elapsed since any episodes of bleeding, resolution of sepsis, or alcohol intake. No patient was taking any drug known to affect primary haemostasis. MAIN OUTCOME MEASURES--Bleeding time as measured with the Simplate double blade template device. A bleeding time longer than 10 minutes was considered abnormal. Other measures were platelet count, prothrombin time, partial thromboplastin time, packed cell volume, and blood urea, serum bilirubin, and serum albumin concentrations, all measured on each subject at the same time by standard laboratory methods. RESULTS--A weak but significant correlation existed between the bleeding time and the platelet count (rs = 0.483; p less than 0.001). There were significantly lower platelet counts, longer prothrombin times, and higher blood urea and serum bilirubin concentrations in the 42 patients with bleeding times of 10 minutes or more compared with the 58 patients with bleeding times less than 10 minutes. Multiple linear regression analysis showed that the bilirubin concentration as well as the platelet count was independently correlated with the bleeding time. The combination of a platelet count greater than 80 x 10(9)/l and a prothrombin time less than 17 seconds (usually taken as safe limits for performing routine liver biopsy) did not predict a normal bleeding time. Ten of 39 patients fulfilling these criteria had a prolonged bleeding time. CONCLUSIONS--Prolonged bleeding time is common in patients with cirrhosis, even in those with prothrombin times and platelet counts within "safe limits" for invasive procedures. The severity of liver disease as assessed by the bilirubin concentration plays an important part in determining the bleeding time in cirrhosis. The bleeding time should be measured when assessing patients for invasive procedures who have a raised bilirubin concentration or poor hepatic function, even if the platelet count and prothrombin time are considered adequate.     

Ecarin test in diagnosis of dicoumarol therapy, liver diseases and DIC

The conversion of prothrombin by ecarin is independent of the presence of gamma carboxyglutamic residues on the N terminal of the molecule. Ecarin converts therefore also the acarboxylated precursor-PIVKA II. In a group of 347 patients under dicoumarol therapy of different intensity and duration PIVKA was detected in BaSO4 adsorbed PPP only in samples where prothrombin level (Quick's test) was lower than 50% of normal values. Increase in PIVKA did not correspond to the decrease of prothrombin. In some cases where the treatment was longer than two years no PIVKA was detected even when prothrombin was under 20%. This is explained by synthesis of partially carboxylated prothrombin molecules, which can be adsorbed. In liver diseases the ecarin test and Quick's time in native, untreated PPP showed about identical decrease of prothrombin level. This indicates that no PIVKA is released to plasma. The functional defect of the hepatocyte does not involve gamma carboxylation as long as vitamin K is provided. In patients with DIC ecarin test showed significantly higher level of thrombin activity than those obtained with Quick's test. It is known that during hypercoagulation stage of DIC prethrombin 1 and 2 are formed by the excess of thrombin. These split products of prothrombin are convertible by ecarin to meizothrombin 1 and 2. A positive ecarin test can be also due to acarboxylated precursors which are released during increased proteosynthesis triggered by consumption coagulopathy.     

Halothane accumulation in rat brain and liver

Halothane concentration (g/g wet weight) was measured in rat brain and liver following exposure to various concentrations of halothane in air. Because of the difficulty of determining the amount of a volatile compound in brain, we analyzed tissue fixed by two different methods. The apparent concentration of halothane in brain was higher following direct decapitation into liquid nitrogen, than after decapitation, removal of fresh tissue, and then freezing. However, the relative effects of altering the inspired concentration were essentially the same in each case. Thus, absolute quantitative accuracy remains a point for discussion; however, we can reach several conclusions regarding the relative accumulation of halothane in brain tissue following various conditions of exposure. Resultant tissue concentrations of halothane were not linearly related to ambient concentrations. Above an inspired concentration of 1.0%, an increase to 1.5% inspired concentration caused little further increase in the halothane concentration in brain, although the liver concentration increased in proportion to the dose increase. Below an inspired concentration of 0.5%, tissue concentrations were less than expected, probably as a result of metabolic degradation occurring at a rate that becomes more noticeable at lower inspired concentrations. Body size was shown to be an important variable affecting the time required for each tissue to reach equilibrium at a given inspired concentration. These data indicate that tissue concentrations at low exposure levels may be less than proportional to dose and that concentrations in small laboratory animals may be expected to exceed values in humans under equivalent conditions of exposure.     

Cerebral energy metabolism during the onset and recovery from halothane anesthesia

Halothane (1%) was administered to twenty-two gram female Swiss-Albino mice which were sacrificed at times of 15 seconds, 45 seconds, 79 seconds and 5 minutes. Additional animals were exposed for 5 minutes and sacrificed 10 minutes after removal from halothane (recovery). Selected energy metabolites were measured in 100–500 nanogram samples from the inferior colliculus and the ascending reticular activating system.Results from this study showed an increase in glucose levels at 79 seconds, when the animals first lost their righting response. The glucose increase was similar in the inferior colliculus and reticular formation. ATP and phosphocreatine were increased at 45 seconds, and during the sleep period in the ascending reticular activiting system, and returned to normal during the recovery period. In the inferior colliculus, ATP was similarly increased from 45 seconds throughout the time course, whereas phosphocreatine was elevated at 79 seconds, and during recovery only. These data suggest a decrease in utilization of energy metabolities during halothane anesthesia, both in cells of the inferior colliculus and ascending reticular activating system.     

The Diagnostic Value of Serum Leucine Aminopeptidase

Experience with serum leucine aminopeptidase determination in 61 patients led to the following conclusions. The test is no more sensitive than the alkaline phosphatase test in cases of carcinoma of the pancreas. It is elevated in all cases of obstructive and hepatogenous jaundice and serves no useful function in their differentiation. It was a valuable test in cases of calculous biliary tract disease, being more sensitive than either bilirubin or alkaline phosphatase determinations. In three instances of elevated leucine aminopeptidase in disorders apparently not related to the liver or pancreas, laparotomy and autopsy showed involvement of these organs in two.     

Hereditary malignant hyperpyrexia associated with muscle adenylate kinase deficiency

Summary Muscle adenylate kinase deficiency was recognized in a family, in which two children died due to malignant hyperpyrexia following halothane anesthesia.Supported by the Deutsche Forschungsgemeinschaft.