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B Doshi and S Sarkar
Topical administration of chloramphenicol can induce acute hepatitis
BMJ 2009; 338: b1699 [Full text]
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[Read Rapid Response] Hepatitis E infection and suspected drug induced liver injury
Richard J Aspinall   (7 September 2009)

Hepatitis E infection and suspected drug induced liver injury 7 September 2009
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Richard J Aspinall,
Consultant Physician & Hepatologist
University Hospital of Wales, Heath Park, Cardiff CF14 4XW, United Kingdom

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Re: Hepatitis E infection and suspected drug induced liver injury

Sir,

Doshi & Sarkar describe a case of acute hepatitis putatively induced by topical chloramphenicol, having apparently excluded “common viruses (hepatitis A, B and C)” as potential causes [1].

However, the authors do not mention whether diagnostic testing for Hepatitis E virus was carried out. This infection must be considered in the differential diagnosis of all cases of acute hepatitis in England and Wales, particularly as most cases reported by the United Kingdom Health Protection Agency lack a personal history of travel to endemic areas [2].

Importantly, acute Hepatitis E infection may be mistaken for an adverse reaction to pharmaceuticals. Dalton and colleagues analysed stored sera from patients with suspected drug induced liver injury meeting the standard Roussel-Uclaf causality criteria used by Doshi & Sarkar [3]. They found evidence of acute Hepatitis E in 6 of 47 samples, concluding that the diagnosis of drug induced liver injury is not secure until the infection has been excluded. I would suggest similar caution be applied here.

[1] Doshi B, Sarkar S. Topical administration of chloramphenicol can induce acute hepatitis. BMJ 2009; 338: b1699

[2] Lewis HC, Boisson S, Ijaz S, Hewitt K, Ngui SL, Boxall E, et al. Hepatitis E in England and Wales. Emerg Infect Dis. 2008;14:165-7

[3] Dalton HR, Fellows HJ, Stableforth W, Joseph M, Thurairajah PH, Warshow U et al. The role of hepatitis E virus testing in drug-induced liver injury. Aliment Pharmacol Ther. 2007;26:1429-35

Competing interests: None declared