Internal Medicine

P1: RLJ/OZN P2: KUF

0521779407-D-01 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 7:41

502 Drug and Toxin-Induced Liver Diseases

■Amanita mushroom poisoning: most cases in U.S. occur in the

Pacific Northwest; ingestion of one mushroom can be fatal; toxin

not destroyed by cooking; OLT frequently necessary

■Aflatoxins: HCC

■arsenic: acute exposure – hepatocellular necrosis; chronic – hepatic

angiosarcoma

■carbon tetrachloride (in cleaning solvents, propellant, fire extingui-

sher): potent hepatotoxin with death from liver failure in first week

■vinyl chloride (in solvents): may result in hepatic fibrosis, noncir-

rhotic portal hypertension, and angiosarcoma

Signs & Symptoms

■systemic features of drug hypersensitivity: fever, rash, eosinophilia,

lymphadenopathy, mononucleosis-like syndrome

■temporal pattern of disease evolution and specific exposure

■presentation generally similar to those of chronic, acute, or fulmi-

nant hepatitis of other etiologies

tests

Basic Tests

■CBC, LFTs, INR, PTT; pH if FHF

■drug levels when available (acetaminophen level)

Imaging

■ultrasound: useful to evaluate hepatic vasculature, hepatic echotex-

ture, signs of portal hypertension

Specific Diagnostic Tests:

■primarily to rule out other causes of liver diseases

■liver biopsy: in general, not useful

differential diagnosis

■chronic liver disease: viral, autoimmune, metabolic, vascular, inher-

ited, cholestatic liver diseases

■acute, subfulminant, fulminant liver disease: other drug reaction,

acute viral hepatitis, acute Wilson’s disease, ischemic hepatitis,

autoimmune hepatitis.

management

What to Do First

■recognition and immediate removal/discontinuation of possible

offending drugs and toxins

General Measures

■general supportive measures for acute liver failure