Autoantibodies against a kidney--liver protein associated with quinolone-induced acute interstitial nephritis or hepatitis

Hypersensitivity reactions to fluoroquinolones

Fluoroquinolone antibiotics cause immediate and delayed hypersensitivity reactions, and may also affect internal organs and circulating blood cells. The underlying pathomechanisms are only partly understood. The extent of cross-reactivity among different quinolones depends on the type of clinical manifestation and its underlying mechanism. Despite recent advances, reliable diagnostic tests are still lacking. Recent studies have shown quinolone-specific IgE in vitro in more than 50% of patients with immediate-type reactions and a considerable cross-reactivity with related compounds. In maculopapular drug exanthems from ciprofloxacin, specific T-cell clones were identified, and cross-reactivity to related compounds was detected in approximately 50% of the clones. From re-exposure studies in patients with exanthems, cross-reactivity appears to be lower. Cellular tests such as lymphocyte transformation tests are currently not very useful. For prick and intradermal skin tests, widely divergent nonirritant test concentrations have been recommended. Desensitization may be possible in selected patients.

Les insuffisances rénales aiguës aux quinolones. Revue générale à propos d'une observation avec cristallisation liée à la ciprofloxacine

A 58 year-old woman developed an acute renal failure very quickly after ingestion of two 500 mg tablets of ciprofloxacin, without any other identifiable risk factor. Renal biopsy was performed. No sign of acute interstitial nephritis was observed but tubular lesions were found, accompanied by deposits of a brown-yellowish substance identified by infrared microscopy as a ciprofloxacin salt. The outcome was favourable. This observation gives the opportunity to remind the different forms of quinolone-induced renal injury and to discuss the possible ways for preventing renal side-effects related to the quinolone use.

Drug- and chemical-induced cholestasis

Cholestasis caused by medicinal and chemical agents is an increasingly well-recognized cause of liver disease. Clinical drug-induced cholestatic syndromes producing jaundice and bile duct injury can mimic extrahepatic biliary obstruction, primary biliary cirrhosis, and sclerosing cholangitis, among others. This article updates the various forms of drug-induced cholestasis, focusing on the clinicopathologic features of this form of hepatic injury and on the known or putative mechanisms by which drugs and chemicals lead to cholestasis.

Quinolone hypersensitivity

PURPOSE OF REVIEW

Quinolones are potent antibacterial agents that can cause drug hypersensitivity reactions affecting different organs. A better understanding of the underlying mechanism and the level of crossreactivity within different quinolones is needed to handle and prevent these diseases.

RECENT FINDINGS

The adverse side-effects caused by quinolones are the result of different immunological mechanisms and cause quite different diseases. The development of an assay detecting quinolone-specific IgE revealed specific antibodies in more than 50% of patients with immediate-type reactions, and the majority of sera also reacted with related compounds. In maculopapular drug exanthemas caused by ciprofloxacin, specific T cells could be detected and cloned. They reacted with ciprofloxacin directly, and crossreactivity to related compounds was detected in approximately 50% of the clones.

SUMMARY

Quinolones can cause drug hypersensitivity reactions by different immunological mechanisms. In-vitro analysis suggests that crossreactivity is common.

Hepatotoxicity of antibiotics and antifungals

Hepatotoxicity associated with any antibiotic is rare. With the wide-spread use of antimicrobial agents, however, hepatic injury is not an infrequent occurrence. Penicillins remain a widely used class of antimicrobials with a well defined record of low hepatotoxicity. The combination of clavulanate with amoxicillin may be associated with the greatest risk for liver injury from any antimicrobial agent. Significant hepatotoxicity also may occur with sulfamethoxazole/ trimethoprim and combination regimens used to treat tuberculosis. An autoimmune-like hepatitis may result from minocycline or nitrofurantoin exposure and most often resolves with cessation of therapy. Treatment with high doses of tetracycline and oxacillin may be associated with severe hepatotoxicity. Early suspicion of hepatocellular injury in the setting of antimicrobial exposure should prompt cessation of therapy and avoidance of rechallenge.

Drug- and chemical-induced cholestasis

Cholestasis resulting from drugs is an increasingly recognized cause of liver disease. It produces a broad clinical-pathologic spectrum of injury that includes simple jaundice, cholestatic hepatitis, and bile duct injury that can mimic extrahepatic biliary obstruction, primary biliary cirrhosis, and sclerosing cholangitis. Although the risk of drug-induced cholestasis leading to a fatal outcome is quite rare, knowledge and recognition of the various forms of cholestatic injury assumes an importance whenever clinicians are confronted with jaundice or other manifestations of liver disease in patients receiving medicinal or chemical agents.