1 / 16

Fishing in Canada may be hazardous to your health: A 55 yo man with nausea

Fishing in Canada may be hazardous to your health: A 55 yo man with nausea. Christie Seibert, MD September 27, 2006. History of Present Illness. 55yo man fishing in Canada, snagged his 3 rd finger on a fishing hook. Initially only painful.

gigi
Download Presentation

Fishing in Canada may be hazardous to your health: A 55 yo man with nausea

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Fishing in Canada may be hazardous to your health: A 55 yo man with nausea Christie Seibert, MD September 27, 2006

  2. History of Present Illness • 55yo man fishing in Canada, snagged his 3rd finger on a fishing hook. Initially only painful. • One week later, started getting red and swollen. • Returned to Madison, went to ER when it started draining pus and looking “angry”.

  3. Other History • PMH • Diabetes (on glargine and asparte insulin, metformin and rosiglitazone. Last HbA1c was 7.5) • HTN(on lotensin) • Hyperlipidemia (on simvastatin) • GERD • SH: Married, home care worker for Hospice, triathlete, non-smoker, no Etoh • ROS: No F/C, malaise

  4. Emergency Room • ER doc incised and drained a small abscess on pt’s 3rd finger. • Gave 2g IV Unasyn and 900mg IV Clinda • Wound cx: MRSA, sensitive to Clinda • Sent home w/ oral Augmentin and Clinda.

  5. 1st Followup Visit (4 d after ER) • Finger still swollen and very painful. Redness is markedly better. No F/C. • Blood sugars higher (160-180’s) than usual (120-130’s). • Antibiotics extended from planned 7 days to 10 days.

  6. 2nd Followup Visit (7d after ER) • Finger still painful and swollen, esp at PIP joint. Sig loss of ROM at PIP joint. • Blood sugars: some > 300. • Developing malaise, severe nausea and epigastric pain. • Xray: Sig DJD of PIP and DIP joints of the 3rd finger. Possible widening of the joint space at the PIP joint. No erosions or active osteo.

  7. Physical Exam • Weight 207 (BMI 29) • BP 112/72 • Sclerae icteric, rest of HEENT WNL • CV, Lungs WNL • Liver edge not palpable, no ascites • Skin: no spider angiomatas or gynecomastia

  8. Testing • MRI: Severe focal osteoarthritis of the third PIP joint. No findings of superimposed septic joint, abscess, osteomyelitis, or foreign body are seen. • Labs: • Alk Phos: 535 • ALT/AST: 401/110 • Total Bili: 5.0 Direct Bili: 3.1 • Nl CBC, lytes, BUN/Cr

  9. Differential Diagnosis?

  10. Amoxacillin-Clavulanic Acid Hepatotoxicity • Learning Objectives • Recognize the possibility of hepatotoxicity from amox-clav acid • Know who might be at highest risk of this adverse reaction • Know how to manage amox-clav acid hepatotoxicity

  11. Pharmacology 101 • Bacteria can produce penicillinases (like B-lactamase) to inhibit penicillin • To combat this, clavulanic acid is added. • Produced from Streptomyces organism • Has a B-lactam ring like penicillin • Acts as “suicide” non-competitive inhibitor, forms inactive complex with B-lactamase

  12. Pharmacology 102 • In vivo spectrum of activity: Staph epi, Enterococci, Bacteroides, other anaerobes • Used in bite wounds, otitis media, sinusitis, lower resp tract and cutaneous infections • Clavulanic Acid (clavulanate) is combined • With Amox (Augmentin) • With Ticarcillin (Timentin)

  13. Amoxacillin-Clavulanic Acid Hepatotoxicity • Rare adverse reaction (1-100/100,000) • Clavulanic acid thought to be culprit • Usually cholestatic picture • Idiosyncratic/not dose-dependent • Time to onset: average 25 days • Prognosis good, usually reversible • Resolution of jaundice by 1-8 weeks, complete recovery in 4-16 weeks

  14. Possible Risk Factors • ? Risk in men (2:1 ratio) • ? Risk over age 60 • ? Risk in longer treatment (>10 days) • ? Risk if previous drug hepatotoxicity • Probably not related • Underlying liver disease • Co-medication with other hepatotoxic drugs

  15. Resolution of Case • Possible hepatotoxic meds were stopped • Amox-clav acid • Rosiglitizone • Metformin • Simvistatin • Hep A, B, C testing negative • Abd ultrasound negative • LFTs peaked with TB at 6-7 range, then resolved over 3 weeks.

  16. Bibliography • Zaidi SA. Hepatitis associated with Amoxacillin/Clavulanic Acid and/or Ciprofloxacin. Amer J Med Sci 2003; 325(1): 31-3. • Dowsett JF et al. Amoxicillin/Clavulanic Acid Induced Intrahepatic Cholestatis. Dig Dis Sci 1989;34(8):1290-3. • Gresser U. Amoxacillin-clavulanic acid therapy may be associated with severe side effects—a review of the literature. Eur J Med Res 2001; 6(4): 139-49.

More Related