Pulmonary Tuberculosis and Hepatitis

Dr Ira Shah

doi:https://10.7199/ped.oncall.2014.64

Pulmonary Tuberculosis and Hepatitis

Dr Ira Shah.

Medical Sciences Department, Pediatric Oncall, Mumbai, India.

ADDRESS FOR CORRESPONDENCE
Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056

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Clinical Problem
A 5½ years old girl presented with fever, jaundice and loss of appetite for 4 days. She was antituberculous therapy {ATT} consisting of Isoniazid {H} and Rifampicin {R} for past 10 months of view of pulmonary TB. On examination, she had jaundice, hepatomegaly. Other systems were normal. Her investigations showed:
• Bilirubin = 3.9 mg, dl
• SGOT = 245 IU, L, SGPT = 225 IU, L
• Total proteins = 7.8 gm, dl, albumin of 3.2 gm, dl

What is the cause of hepatitis_?

Discussion
The single biggest problem in the treatment of TB is drug induced liver dysfunction, which has a mortality of upto 13 percent {1,2}. Pyrazinamide {PZA}, Isoniazid {INH} and Rifampicin {RIF} are hepatotoxic drugs in decreasing toxicity{3}. Isoniazid causes hepatitis due to the formation of hydrazines. They are formed by the action of P450 on acetylhydrazine, a product of isoniazid metabolism in the liver. The hydrazines get covalently bound to liver proteins thus damaging the cells. {4} Rifampicin induces P450 enzymes and therefore increases the risk of hepatotoxicity when given with Isoniazid. {5} Pyrazinamide on the other hand causes direct liver toxicity which is dose related. {5} However, ATT induced drug toxicity is seen more in the intensive phase and less commonly in the continuation phase. {6} Though this child has hepatitis, and is on ATT, drugs may not be the cause of jaundice as the child has been on treatment for the past 10 months. Thus, one should also keep-in-mind, other causes of acute hepatitis such as Hepatitis A and Hepatitis E before this is considered as drug induced hepatitis. In this child, Hepatitis A IgM was positive and child improved gradually. Thus, this was Hepatitis A and not drug induced hepatitis.

Compliance with ethical standards

Funding: None

Conflict of Interest: None

References

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