GASTROENTEROLOGY
1992;103:1925-1927
CASE REPORTS
Hypersensitivity With Hepatotoxicity to Mesalazine After Hypersensitivity to Sulfasalazine MARC L. HAUTEKEETE, NADINE BOURGEOIS, PHILIPPE POTVIN, LIEVE DUVILLE, HENDRIK REYNAERT, GHISLAIN DEVIS, MICHAEL ADLER, and GUNTER KLGPPEL Departments of Hepatogastroenterologv -. Free University _ __ and Pathology, and HBpital Erasme-ULB), Brussels, Belgium
A 81-year-old woman with Crohn’s disease of the colon developed a skin rash after 3 weeks of treatment with sulfasalazine. Administration of sulfasalazine was discontinued. When mesalazine was instituted 1 week later, she developed a severe hypersensitivity reaction characterized by fever, diarrhea, skin rash with subsequent desquamation, marked atypical lymphocytosis, and severe hepatotoxicity. Recovery was complete. The clinical and biological features as well as liver pathology of this case bear a striking resemblance to earlier reports of hypersensitivity reaction with severe hepatotoxicity to sulfasalazine. The authors urge caution when mesalazine is given to a patient with known hypersensitivity to sulfasalazine.
S
ulfasalazine is an effective drug for treatment of inflammatory bowel disease, but its use is compromised by several side effects,‘,’ including potentially severe hepatotoxicity.3-‘0 Recently, mesalazine and olsalazine, new preparations of 5-aminosalicylic acid, have been introduced in the hope that these molecules would not show sulfasalazine-induced side effects. The present report describes a case of a systemic hypersensitivity reaction with severe hepatotoxivity to mesalazine. Case Report The patient, a 21-year-old woman, had a history of allergic asthma bronchiale and rhinitis in childhood. A paternal aunt and cousin also had asthma. In May 1991 Crohn’s disease of the colon was diagnosed in the patient; the terminal ileum was unaffected. Liver test results were normal. On May 17, treatment with methylprednisolone, 48 mg/day, and sulfasalazine, 1.5 g/day, was initiated; after 1 week sulfasalazine was increased to 3 g/day and methylprednisolone was tapered to 16 mg/day. On June 9, she presented a generalized itching maculopapular rash; sulfasalazine was discontinued, and the rash disappeared
of Brussels [Academic Hospital-VUB
within 4 days. On June 15, treatment with mesalazine (Asacol; Byk Belga, Brussels, Belgium), 400 mg twice a day, was started. On June 16 she developed a generalized itching rash accompanied by tiredness, headache, myalgias, arthralgias, and nausea. The next day, she also experienced severe watery diarrhea, abdominal pain, and high bouts of fever up to 39.5”C. She was admitted to the hospital. Physical examination showed the presence of a generalized, focally confluent maculopapular rash and mild conjunctivitis; a few small lymph nodes were palpable. Leucocyte level was 26.7 X lO’/L with 39% neutrophils, 40% lymphocytes, 10% atypical lymphocytes, 3% monocytes, and 2% eosinophils. Serum aspartate aminotransferase (AST) level was 49 IU/L (normal
1992;103:1925-1927
CASE REPORTS
Hypersensitivity With Hepatotoxicity to Mesalazine After Hypersensitivity to Sulfasalazine MARC L. HAUTEKEETE, NADINE BOURGEOIS, PHILIPPE POTVIN, LIEVE DUVILLE, HENDRIK REYNAERT, GHISLAIN DEVIS, MICHAEL ADLER, and GUNTER KLGPPEL Departments of Hepatogastroenterologv -. Free University _ __ and Pathology, and HBpital Erasme-ULB), Brussels, Belgium
A 81-year-old woman with Crohn’s disease of the colon developed a skin rash after 3 weeks of treatment with sulfasalazine. Administration of sulfasalazine was discontinued. When mesalazine was instituted 1 week later, she developed a severe hypersensitivity reaction characterized by fever, diarrhea, skin rash with subsequent desquamation, marked atypical lymphocytosis, and severe hepatotoxicity. Recovery was complete. The clinical and biological features as well as liver pathology of this case bear a striking resemblance to earlier reports of hypersensitivity reaction with severe hepatotoxicity to sulfasalazine. The authors urge caution when mesalazine is given to a patient with known hypersensitivity to sulfasalazine.
S
ulfasalazine is an effective drug for treatment of inflammatory bowel disease, but its use is compromised by several side effects,‘,’ including potentially severe hepatotoxicity.3-‘0 Recently, mesalazine and olsalazine, new preparations of 5-aminosalicylic acid, have been introduced in the hope that these molecules would not show sulfasalazine-induced side effects. The present report describes a case of a systemic hypersensitivity reaction with severe hepatotoxivity to mesalazine. Case Report The patient, a 21-year-old woman, had a history of allergic asthma bronchiale and rhinitis in childhood. A paternal aunt and cousin also had asthma. In May 1991 Crohn’s disease of the colon was diagnosed in the patient; the terminal ileum was unaffected. Liver test results were normal. On May 17, treatment with methylprednisolone, 48 mg/day, and sulfasalazine, 1.5 g/day, was initiated; after 1 week sulfasalazine was increased to 3 g/day and methylprednisolone was tapered to 16 mg/day. On June 9, she presented a generalized itching maculopapular rash; sulfasalazine was discontinued, and the rash disappeared
of Brussels [Academic Hospital-VUB
within 4 days. On June 15, treatment with mesalazine (Asacol; Byk Belga, Brussels, Belgium), 400 mg twice a day, was started. On June 16 she developed a generalized itching rash accompanied by tiredness, headache, myalgias, arthralgias, and nausea. The next day, she also experienced severe watery diarrhea, abdominal pain, and high bouts of fever up to 39.5”C. She was admitted to the hospital. Physical examination showed the presence of a generalized, focally confluent maculopapular rash and mild conjunctivitis; a few small lymph nodes were palpable. Leucocyte level was 26.7 X lO’/L with 39% neutrophils, 40% lymphocytes, 10% atypical lymphocytes, 3% monocytes, and 2% eosinophils. Serum aspartate aminotransferase (AST) level was 49 IU/L (normal
