werner@aecom.UUCP (Craig Werner) (02/12/86)
> Another patient comes into the hospital heavily jaundiced. (And, the > whites of BOTH eyes are deeply orange.) He had been seen in clinic for > another (and for this puzzle, unimportant) illness two weeks earlier and had > been prescribed tetracycline based on a history of Penicillin allergy. > Other than that, he had been previously healthy. > To confirm the initially obvious diagnosis, a liver biopsy is done, > and much to the suprise of the residents, it does not reveal membrane bound > fat accumulation typical of idiosyncratic Tetracycline toxicity, but rather > large quantities of iron in almost all the liver cells. > The blood count is normal, as is the hematacrit, so there is no > sign of hemolytic anemia, or increased Red Blood Cell destruction. > > 1. What was overlooked, and what needs to be done to remedy the > situation? > 2. What is your best guess as to the cause of the liver failure? If you didn't pick it up, a RARE reaction to Tetracycline is to develop a fatty liver, with secondary failure if severe enough. The reaction is idiosyncratic, meaning there is no way to predict in advance that it is going to happen to any given person, but known. Other causes of Fatty liver include Alcohol consumption (the #1 cause) and Carbon Tetrachloride. However, in the latter the fat is free in the cytosol, and in the former, it is membrane bound. The two look distinctive enough not to be confused. Incidentally, it gets better if you stop the antibiotic, ditto the alcohol. However, that's NOT what the patient had at all. Tet toxicity does not cause Iron accumulation in the liver. (which is a test result, not a symptom) What does cause Iron to accumulate in the liver: the number one cause is Red Blood Cell destruction - hemolysis. This is called Hemosiderosis. Another cause for the St. Elsewhere fans on net.med, the liver may congenitally be unable to rid itself of Iron and it accumulates in the liver and pancreas over a lifetime -- this is Hemochromatosis. The last reason is the accumuation of Iron due to excessive intake -- since men can only remove 1 mg/day from the body, women slightly more due to menstruation. Answers: What had been overlooked? Well, the patient had been asked what medication he had been taking. He answered Tetracycline. What should have also been asked was whether he was taking anything else non-prescription or otherwise on his own. As it turned out, the answer was "Yes." He had been told to take a gram of Vitamin C a day by a well-meaning friend, and instead of doing that, he took 12 Multivitamins+Iron (well, 80mg each * 12 = 960mg ~= 1g) on the assumption that if C was good A-E+ would be even better. The diagnosis: Hypervitaminosis Iron (essentially Heavy Metal poisoning). Alternate phrasing (a sort of pun for those who really know liver: 'Chronic Active Gullibility/Stupidity with Acute Exacerbation.' Treatment: Talk to the patient. Convince him of the error of his ways. Also: Deferoxamine, a highly specific Iron chelating agent might speed up the recovery (which would happen anyway, albeit slowly.) -- Craig Werner !philabs!aecom!werner "..pursuing Dharma, Artha, and Kama (although not nearly enough of the last)."