Wysypka skórna i uszkodzenie wątroby wywołane ceftriakszonem u pacjenta z markerem genetycznym HLA-B*15:02, tolerującego okskarbamazepinę przez 20 lat - opis przypadku
Ceftriaxone-induced drug eruption with concurrent liver injury in an HLA-B*15:02-positive patient tolerant to oxcarbazepine for 20 years: a case report
W skrócie
[Preprint - wstępne wyniki] Młody pacjent z epilepsją, przez 20 lat bez problemów przyjmujący okskarbamazepinę, otrzymał ceftriakszown na zapalenie płuc i rozwinął wysypkę skórną wraz z uszkodzeniem wątroby. Po wdrożeniu odpowiedniego leczenia (zastąpienie antybiotyku, sterydy, kontynuacja okskarbamazepiny) objawy ustąpiły i pacjent powrócił do zdrowia. Przypadek pokazuje, że genetyczny marker HLA-B*15:02 nie dyskwalifikuje stosowania okskarbamazepiny, a ceftriakszown może powodować jednocześnie problemy skórne i wątrobowe.
Oryginalny abstract (angielski)
A 27-year-old Han Chinese man with epilepsy had taken oxcarbazepine for 20 years without any cutaneous adverse effect and was known to carry HLA-B*15:02. He was admitted with convulsive status epilepticus complicated by Staphylococcus hominis pneumonia, having received intravenous ceftriaxone at a referring hospital. On day 5 of ceftriaxone a pruritic maculopapular eruption appeared on the hands and generalised within 24 hours; a single dose of phenobarbital was given in the emergency department before his recorded phenobarbital hypersensitivity was retrieved, and was then stopped permanently. Liver biochemistry showed a mixed hepatocellular-cholestatic pattern (R value approximately 2.3) with hypoalbuminaemia and no eosinophilia. Because two decades of tolerance were documented, oxcarbazepine was continued; ceftriaxone was withdrawn and norvancomycin substituted, with antihistamines, intravenous methylprednisolone and supportive care. The eruption resolved, liver biochemistry returned towards baseline and he was discharged on day 13. The RUCAM score for ceftriaxone-associated liver injury was 7, a probable association. The case shows that HLA-B*15:02 is a risk marker rather than a contraindication to oxcarbazepine, that documented tolerance carries diagnostic weight when a patient exposed to several drugs develops a rash, and that ceftriaxone can cause cutaneous and hepatic injury together.