此病例為一頸部淋巴腺結核病患,服用四種抗結核病藥物-INAH(Isoniazid)、RIF(Rifampin)、EMB(Ethambutol)及PZA(Pyrazinamide)一個月後,出現急性肝炎,生化值GOT 1074 U/L,GPT 1369 U/L,total bilirubin 2.1 mg/dL。經排除其他因素以及重新給藥後,推測高劑量的PZA(31.25 mg/kg/day)應和此次肝毒性有關。因此,將處方改為INAH、RIF、EMB及Streptomycin。
使用更改後之處方一個月後,病人出現嚴重皮膚過敏反應。血液檢查報告亦顯示eosinophil 8.1 %(正常值:0-5 %)以及absolute eosinophil count 368/μL(正常值:50-350/μL)。後經重新給藥證實是RIF造成此次過敏反應。於是再將處方改為INAH、EMB、Streptomycin及Ciprofloxacin。
This case was a cervical lymph node tuberculosis (Scrofula) patient undertaking treatment with four antituberculosis drugs — INAH (isoniazid), RIF (rifampin), EMB (ethambutol) and PZA (pyrazinamide). One month later, she developed acute hepatitis with symptoms of nausea, vomiting, fatigue and anorexia and GOT/GPT levels reached 1074/1369 (U/L). Total bilirubin also rose to 2.1 mg/dL. After excluding other possible causing factors and restarting antituberculosis medications, high dose PZA (31.25 mg/kg/day) was highly suspected to be associated with hepatotoxicity happened in this case. Hence, we changed the treatment regimen to INAH, RIF, EMB and streptomycin.
One month after using the modified regimen above, the patient noticed the appearance of rashes, pruritus, intraoral ulcers, perioral paresthesia and swelling of the oral mucosa. Hematologic parameters were 8.1 % eosinophils normal 0-5%) and absolute eosinophil count 368/μL (normal 50-350). From the rechallenge data, we verified RIF was the culprit. Treatment finally consisted of INAH, EMB, streptomycin and ciprofloxacin.
Discussing the mechanism and management of PZA-associated acute hepatitis and RIF-induced cutaneous hypersensitivity will also be included in this article.