Failure of physicians to recognize acetaminophen hepatotoxicity in chronic alcoholics

Article Abstract:

Acetaminophen is the most widely used and known over-the-counter nonaspirin pain reliever. Acetaminophen is often recommended for those at risk of ulcers, because unlike aspirin, it has no known association with ulcer disease. The major toxicity of acetaminophen is liver damage, but in healthy patients, this is generally only seen in cases of intentional overdose. Because alcoholics have a greater tendency than nonalcoholics to experience gastrointestinal bleeding, most physicians advise their alcoholic patients to use acetaminophen when they need a pain reliever. In normal, therapeutic doses, acetaminophen can cause severe liver damage in chronic alcoholics. Six cases of such liver disease in alcoholics are described. In several of these cases, the patients entered the hospital with markedly abnormal blood tests of liver function, and these were attributed to acute alcoholic hepatitis (inflammation of the liver). Only after several days did the history of acetaminophen use become known. Four of the six recovered liver function spontaneously, over the course of their hospitalizations, while the other two developed severe infectious complications from their underlying diseases, and died. In several of these cases, the diagnosis was made by consultants, as the primary care physicians continued to believe that the patients were suffering from alcoholic hepatitis. Because the liver function test results were extremely abnormal, which is not consistent with alcoholic hepatitis, the physicians should have been searching for an alternative explanation for the patients' illnesses. Acetaminophen toxicity must be considered in the differential diagnosis of an alcoholic who shows signs of acute liver disease, even in the absence of a history of excessive use of acetaminophen. (Consumer Summary produced by Reliance Medical Information, Inc.)

Liver diseases, Diseases, Acetaminophen, Alcoholics

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Quinine hepatotoxicity: an underrecognized or rare phenomenon?

Article Abstract:

Quinine and quinidine are drugs derived from the bark of the cinchona tree. Although the two compounds are optical isomers, and usually produce the same side effects, liver injury has frequently been recorded in quinidine treatment, while it is apparently rare with quinine use. However, in the case of a 37-year-old woman, a series of symptoms including fever, chills, headache, blurred vision, joint pain, muscle pain, nausea, and diarrhea were found to be associated with a regimen of 300 milligrams of quinine sulfate twice daily, which was prescribed for leg cramps. The quinine treatment was discontinued upon admission to the hospital, and resolution of both fever and abnormal liver tests ensued. With the patient's permission, a dose of 260 milligrams of quinine sulfate was administered to induce an immune response; symptoms reappeared within hours. Within 48 hours, there was a modest rise in aspartate aminotransferase and alanine aminotransferase, indicating some liver dysfunction; alkaline phosphatase and bilirubin were normal. The authors suggest that since the symptoms of this woman resembled that of a viral infection, there may be more hypersensitivity to quinine than has been previously recognized. Quinine may also be responsible for some so-called 'idiopathic' (unknown origin) cases of liver injury. In addition to its widespread use in the treatment of leg cramps and the prevention of malaria, quinine is also freely available in tonic water and bitter lemon. Although the actual frequency of adverse effects due to quinine needs to be established, specific questioning about quinine use might be appropriate for patients with symptoms resembling those discussed in this case. (Consumer Summary produced by Reliance Medical Information, Inc.)

Liver, Quinine

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Muscle cramps

Article Abstract:

Cramps, or involuntary skeletal muscle contractions, are frequent patient complaints and may be classified into specific categories of true cramp, tetany, contracture, or dystonia. The pathophysiology and clinical features of each type of cramp is described. True cramp may be subdivided into ordinary cramps and cramps due to disease of the lower motor nerves, heat, fluid and electrolyte disorders, drugs, and hemodialysis, a procedure for artificially filtering the blood. Contractures are rare muscle cramps that occur during exercise and may be associated with muscle damage and myoglobinuria, the presence of the oxygen-carrying muscle pigment called myoglobin in the urine. Hyperthyroid myopathy, or muscle disease associated with increased activity of the thyroid gland, may be accompanied by the development of severe muscle cramps which occur spontaneously or after exertion. Tetany is characterized by an initial tingling sensation or numbness of the muscles in the mouth, hands, and lower legs, followed by muscle spasms, twitches, and painful contraction. Occupational cramps are a type of dystonia, or condition of impaired muscle tone. They occur in persons who have spent years mastering the fine hand motor control required for a specific task, and may develop in writers, pianists, and typists. The diagnosis of cramps includes an evaluation of patient history, physical examination, and if necessary, routine laboratory testing. The most effective treatment for cramps is stretching exercises and the drug quinine. (Consumer Summary produced by Reliance Medical Information, Inc.)

Identification and classification

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