Updates-By Carol A. Kemper, MD, FACP
Updates-By Carol A. Kemper, MD, FACP
First Fatality to RIF-PZA for Latent Tuberculosis
Source: CDC. MMWR Morb Mortal Wkly Rep. 2001;50:289-291.
This report describes the first fatality due to drug-induced hepatitis in an incarcerated 53-year-old man who received a combination of rifampin (RIF) and pyrazinamide (PZA) for latent tuberculosis (TB). Apparently, a 2-month regimen of RIF-PZA is a standard approach for latent TB without evidence of active disease at this correctional facility. The man was in good health, had no history of hepatitis, and was receiving no other agents with significant hepatotoxicity.
Blood tests performed at 1 month of therapy showed grade 4 hepatotoxicity (bilirubin 4.2 mg/dL and transaminases > 10 × ULN). Two days later, when the results of the laboratory studies became available, both drugs were stopped. Despite persisting symptoms of lassitude and nausea, the patient initially failed to report to the infirmary for evaluation and care. Five days after stopping medications, he was admitted with severe jaundice and altered mental status. He died 3 days later of hepatic necrosis.
A second report describes a 59-year-old previously healthy woman who also received a combination of RIF-PZA for a positive skin test with subsequent life-threatening hepatotoxicity. The patient reported some initial queasiness, but laboratory studies obtained on day 17 of therapy showed only eosinophilia and normal transaminases. She developed progressive anorexia, malaise, and low-grade fever but continued drug therapy until, on the 49th day of treatment, she was admitted with jaundice and altered mental status. Laboratory studies suggested a hypersensitivity reaction with eosinophilia and a positive ANA. She received prednisone, and eventually recovered after a lengthy 4-week hospitalization.
Ironically, the woman elected to receive this particular prophylactic regimen because of concerns regarding potential hepatotoxicity to INH and possible exposure to multidrug resistant TB.
Treatment in both cases was provided for latent TB without evidence of active infection. CXRs in both cases were normal. And, although this report did not indicate whether either patient had converted their skin test, it appears that neither case was considered high risk. It is important to recognize that both cases occurred despite prospective monitoring of laboratory studies at about 2-4 weeks of therapy. In both cases, therapy was continued despite symptoms of possible toxicity, at least until overt evidence of hepatic injury. Patients receiving antituberculous therapy should be warned to stop their therapy should they develop any signs or symptoms of hepatic toxicity. This CDC report serves as a reminder that laboratory screening of these patients is not a substitute for good clinical monitoring.
But What About Dogs and E coli?
Source: ProMED-mail post; www.promedmail.org, accessed May 8, 2001.
The first documented case of transmission of E coli 0157:H7 from a dog to a human has been reported in England. The dog was elderly, incontinent of both urine and stool, and described as "largely immobile." He had been kindly taken in by a family 2 months earlier. Their 3-year-old child developed bloody diarrhea and subsequently required hospitalization with hemolytic-uremic syndrome. Fecal samples from the dog were positive for E coli 0157. The case probably would not have come to light except that the family is vegetarian, raising suspicions of an atypical source. Although the report did not allude to this, one wonders if the dog’s enteric infection contributed to his overall weakened and incontinent condition.
How the dog acquired E coli 0157 is a matter of speculation. During the 2 months he lived with the family, he was primarily fed a commercially-prepared dry dog food, which according to the manufacturer is heated and sterilized. Whether it was fed raw eggs or table scraps, such as undercooked hamburger meat, before being taken in by the family is not known. Dogs fed table scraps or undercooked meat may be at risk for acquisition of E coli 0157.
Vaginal Douching and PID
Source: Ness RB, et al. Sex Transm Dis. 2001;28:240-245.
This large-scale, multicenter evaluation of pelvic inflammatory disease (PID; "cleverly" termed the PEACH Study for PID Evaluation and Clinical Health) examined risk factors in 654 women with and without endometritis and upper genital tract infection (UGTI). Douching—either more than once monthly or within 6 days of the onset of symptoms—was a significant risk factor for UGTI. Even after controlling for various confounding factors, such as ethnicity and presence of bacterial vaginosis, douching remained a significant risk behavior. Although it would not be surprising if douching increased the risk of UGIT in women with STDs, even women with normal vaginal flora in this study who douched more often were at greater risk for UGTI.
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