Flucloxacillin-Induced Hepatotoxicity - Association with HLA-B*5701

SUMMARY Drug-induced liver injury (DILI) to flucloxacillin is rare and is classified as idiosyncratic, as it is dependent on individual susceptibility, unpredictable, and dose-independent. The authors present the case of a 74 - year - old man with a history of monoclonal gammopathy under investigation and alcoholic habits of 24 g/day, with asthenia, anorexia, nausea, abdominal discomfort, and fever with three days of evolution. He was treated with two courses of antibiotic therapy with flucloxacillin to erysipelas previously (3 months and 2 weeks before admission). Lab tests showed serum AST levels of 349 U/L, ALT 646 U/L, alkaline phosphatase 302 U/L, GGT 652 U/L, total bilirubin 3.3 mg/dL and direct bilirubin 2.72 mg/dL. Infectious, autoimmune, and metabolic causes were ruled out. Magnetic resonance cholangiopancreatography showed normal results. Liver biopsy showed mild multifocal (predominantly microvesicular) steatosis; marked changes in the centrilobular areas (sinusoidal dilatation, marked congestion, hemorrhage, and multifocal hepatocyte collapse); expansion of the portal areas with the formation of bridges; proliferated bile ducts and inflammatory infiltrate of variable density, predominantly mononuclear type. The HLA-B*5701 screening test was positive. Hepatic biochemical tests remain abnormal with a significative increase in total bilirubin, which reached levels of 24.1 mg/dL, with the development of jaundice, pruritus, and choluria. DILI was assumed, and the patient was treated with ursodeoxycholic acid. There was favorable evolution, without evidence of blood coagulation dysfunction or encephalopathy. The analytic normalization was, however, slow, with evolution to chronicity. The authors present this case to remind the possibility of moderate/severe drug-induced liver injury to flucloxacillin, an antibiotic commonly used in clinical practice and association with the HLA-B * 5701 allele reported in the literature.

RESUMO A hepatotoxicidade à flucloxacilina é rara e classifica-se como idiossincrática, uma vez que é dependente da suscetibilidade individual, não expectável e independente da dose. Apresentamos o caso de um homem, 74 anos, antecedentes de gamapatia monoclonal e hábitos alcoólicos de 24 g/dia, com quadro de astenia, anorexia, náuseas, desconforto abdominal e febrícula com três dias de evolução. Referência a dois ciclos de antibioterapia com flucloxacilina por erisipela (três meses e duas semanas antes da admissão). Analiticamente com AST 349 U/L, ALT 646 U/L, FA 302 U/L, GGT 652 U/L, bilirrubina total 3,3 mg/dL, bilirrubina direta 2,72 mg/dL. Excluídas etiologias infecciosa, autoimune, metabólica, bem como patologia das vias biliares por colangio-RM. Biópsia hepática mostrou esteatose multifocal ligeira (predominantemente microvesicular); alterações acentuadas nas áreas centrolobulares (dilatação sinusoidal, congestão acentuada, hemorragia e colapso multifocal de hepatócitos); expansão das áreas portais com constituição de pontes; ductos biliares proliferados e infiltrado inflamatório de densidade variável, predominantemente de tipo mononucleado. Tipagem de HLA-B*5701 positiva. Agravamento analítico atingindo bilirrubina total 24,1 mg/dL, com desenvolvimento de icterícia, prurido e colúria. Admitida a hepatotoxicidade, iniciou terapêutica com ácido ursodesoxicólico. Verificou-se evolução favorável, sem evidência de coagulopatia ou encefalopatia. A normalização analítica foi, no entanto, lenta, com evolução para cronicidade. Os autores apresentam este caso para alertar para a possibilidade de hepatotoxicidade moderada a grave à flucloxacilina, antibiótico de uso comum na prática clínica e associação com o alelo HLA-B*5701 relatada na literatura.

Validation of a Rapid, Robust, Inexpensive Screening Method for Detecting the HLA-B*58:01 Allele in the Prevention of Allopurinol-Induced Severe Cutaneous Adverse Reactions

The HLA B*58:01 allele has been worldwide reported as a pharmacogenetic susceptibility to allopurinol-induced severe cutaneous adverse reactions (SCARs). To prevent these life-threatening conditions, the American College of Rheumatology hingly recommended that the HLA-B*58:01 be screened prior to the initiation of allopurinol therapy. Therefore, we developed a rapid, robust, inexpensive screening method using SYBR® Green real time PCR to detect the HLA-B*58:01 allele. A total of 119 samples were tested. The assay has a sensitivity of 100% (95% CI: 69.15%-100%), a specificity of 100% (95% CI: 96.67%-100%), a positive predictive value of 100% (95% CI: 69.15%-100%) and a negative predictive value of 100% (95% CI: 96.67%-100%). HLA-B*58:01 genotyping results showed 100% agreement with those obtained from Luminex SSO/SBT/SSP. The lowest limit of detection of this method is 0.8 ng/µL of DNA. The unit cost of the test is only $3.8 USD. This novel screening test using SYBR® real time PCR would be appropriate to identify individuals with the HLA-B*58:01 allele for the prevention of allopurinol-induced SCARs.

HLA-B*1502 and carbamazepine-induced severe cutaneous adverse drug reactions in Vietnamese

BACKGROUND: In Vietnam, we observed a high incidence of carbamazepine (CBZ)-induced severe cutaneous adverse drug reactions (SCARs)-Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN), and drug-induced hypersensitivity rash with eosinophilia and systemic symptoms (DRESS). In other Asian countries, HLA-B*1502 is an established risk factor for SCARs. OBJECTIVE: The aim of our study was to determine the frequency of HLA-B*1502 in SCARs patients at a large University Medical Center in Hanoi, Vietnam. METHODS: Thirty-eight cases of SCARs caused by CBZ and 25 patients with epilepsy tolerating CBZ were enrolled in a case-controlled study. Clinical manifestations and laboratory findings were recorded for each subject. Genomic DNA was isolated using the QIAamp DNA purification system. The combination of polymerase chain reaction and sequence specific oligonucleotide probes with the Luminex 100×MAP flow cytometry dual laser system was then used to quantitate fluorescently labelled oligonucleotides attached to colour-coded microbeads. RESULTS: Cases comprised 20 SJS (52.6%), 7 TEN (18.4%), 8 overlap syndrome (21.1%), and 3 DRESS patients (7.9%). A strong association between HLA B*1502 and bullous skin reactions such as SJS/TEN and overlap was confirmed with an odds ratio (OR) of 33.78 (95% confidence interval [CI], 7.55-151.03), p < 0.0001, Sensitivity 91.4%, Specificity 76.0%, positive predictive value 84.2%, and negative predictive value 86.4%. We did not, however, observe any correlation between the presence of this allele and CBZ-induced nonbullous skin reactions (DRESS) (OR, 6.33; 95% CI, 0.48-82.74; p = 0.1592). CONCLUSION: Our results indicate the presence of HLA-B*1502 in Vietnamese is a pharmacogenetic risk factor for developing CBZ-induced SJS/TEN.

The influence of human leucocyte antigen-Ⅰ polymorphisms on plasma viral load in human immunodeficiency virus infected male homosexual population in Beijing / 中华传染病杂志

Objective To analyze the influence of the polymorphisms of human leucocyte antigen (HLA)-Ⅰ molecule and the effects on plasma viral load of human immunodeficiency virus (HIV) infected male homosexual population in Beijing.Methods The HLA-A,HLA-B,HLA-C allele were typed by sequence specific primer-polymerase chain reaction (SSP-PCR),and viral load was detected in 157 chronic HIV infected persons.Normally distributed measurement data were analyzed by one-way or multi-way analysis of variance,while data of abnormal distributions were analyzed by Mann-Whitney U test.Results Among 157 chronic HIV infected persons,the number of Bw4 motifs on HLA-B loci was associated with a lower level of viral load (F=3.01,P=0.045).In these HIV infected persons,the viral load in HLA-B carrying Bw4/4 homozygote was (4.19±0.76) lg IU/mL,in HLA-B carrying Bw6/6 homozygote was (4.63±0.74) lg IU/mL (t=2.27,P=0.010).The viral load of those who carried three,one or none Bw4 motifs on HLA-A and HLA-B loci were (3.92± 0.97),(4.54±0.88) and (4.60±0.72) lg IU/mL,respectively (three vs none:t=2.53,P=0.015; three vs one:t=2.11,P=0.039).HIV infected persons who carried homozygote on any loci of HLA-A,HLA-B,HLA-C had comparable levels of plasma viral load to those who carried heterozygote on HLA-A,HLA-B,HLA-C loci.Among the persons who carried heterozygote on HLA-A,HLA B,HLA-C loci,Bw4/4 homozygote on HLA-B had lower levels of viral load than Bw6/6 homozygote on HLA-B (median:4.09 lg IU/mL vs 4.55 lg IU/mL,U=210.50,P=0.041).HIV infected persons who carried A30/B13/C06 or A33/B58/C03 haplotype had comparable levels of plasma viral load to those without A30/B13/C06 or A33/B58/C03 haplotype (t=0.40,P=0.69; t=0.68,P=0.49,respectively).Conclusions Bw4/4 homozygote on HLA-B loci is associated with lower HIV viral load.Furthermore,the plasma viral load of HIV infected persons carrying heterozygote on HLA-A,HLA-B,HLA-C loci could be influenced by the Bw4/4 homozygote on HLA-B locus,with a lower viral load.

Impact of human leukocyte antigen-B specific Bw4 epitope on hepatitis C virus infection / 中华传染病杂志

Objective To study the impact of human leukocyte antigen (HLA)-B specific Bw4 epitope on disease progression of hepatitis C virus (HCV) infection.Methods Eighty-six cases of HCV infection through paid blood donation were enrolled in the study.Enzyme-linked immunosorbent assay (ELISA) to detect HCV IgG and IgM,real-time reverse transcriptation polymerase chain reaction (RT-PCR) to detect HCV RNA,and sequence specific primer-polymerase chain reaction (SSP-PCR) to analyze HLA type was performed.Categorical data were analyzed by chi-square test,and measurement data were compared by independent sample t test.Results Among the 86 HCVinfected individuals,there were 29 (33.7 ％) cases of Bw4/4 homozygote,38 cases (44.2 ％) of Bw4/6 heterozygote and 19 (22.1％) cases of Bw6/6 homozygote.The HCV RNA levels in Bw4/4 group,Bw4/6 group and Bw6/6 group were (3.98±0.32),(5.22±0.29),(5.04±0.38) lg IU/mL,respectively.The HCV RNA level in Bw4/4 group was significantly lower than those in the other two groups (t=2.821,P=0.0063 ; t =2.106,P =0.0407,respectively).The spontaneous clearance rates of Bw4/4 group,Bw4/6 group and BW6/6 group were 58.6％,26.3％ and 21.0％,respectively.The spontaneous clearance rate of Bw4/4 group was significantly higher than those of Bw4/6 group and Bw6/6 group (x2 =7.135,P =0.008; x2 =6.583,P =0.010,respectively).HCV infected individuals with homozygous epitopes of Bw4/4 had 4.351 times higher probability of spontaneous viral clearance than that of Bw4/6 heterozygote or Bw6/6 homozygote (OR=4.351,95％CI:1.676-11.294).Conclusions Homozygosity for HLA-Bw4-bearing B alleles is associated with significant lower HCV viral load and higher spontaneous clearance rate.The HLA-Bw4 epitopes have a protective effect against HCV infection.

A Case of Hypersensitivity Reaction Induced by Abacavir in an AIDS Patient / 대한내과학회지

Abacavir is a nucleoside reverse transcriptase inhibitor that is commonly used in HIV-infected patients. A well-known and potentially life-threatening side effect of abacavir is allergic hypersensitivity reaction. A screening test for the HLA-B*5701 allele is currently used to predict the risk of hypersensitivity reaction to abacavir. This test, however, may be less useful in Korea, because of the low prevalence of HLA-B*5701. A 52-year-old male with HIV infection was referred to our hospital because of suspected side-effects of antiviral agents and lymph node enlargement of the neck. He suffered from a fever, generalized edema, skin rash of the whole body, and difficulty breathing after starting antiviral agents. Suspected as a hypersensitivity reaction resulting from drug side-effects, prescription of abacavir was stopped. The patient subsequently recovered. The presence of the HLA-B*5701 allele was confirmed by polymerase chain reaction-sequencing based typing (PCR-SBT).

Simultaneous mutations in exon and intron of a novel human leukocyte antigen-B*3818 allele revealed by genomic sequence analysis / 中华检验医学杂志

Objective To analysis the genomic sequence of a novel human leukocyte antigen (HLA)-B*3818 allele.Methods Full length genomic sequence of an unknown HLA-B allele was cloned,followed by bi-directional sequencing and the specificity of the antigen coded by this novel allele was defined by microcytotoxicity assay.The frequency and haplotype of this novel allele was acquired by population census and parentage analysis.Results The full length genomic sequence of this novel HLA-B*3818 allele with accession number FJ561482 differs from HLA-B*380201 by two nucleotide changes in exon 4 and intron 5,respectively.One change is located at nt 660 in exon 4 where C→A alternation,which results in an amino acid substitution from Asp(GAC)to Glu(GAA)at codon 196.This alternation is a new single nucleotide polymorphism compared with all other HLA-B alleles.Another is located at genomic position 2133 in intron 5(A→C).Except for this substitution,the intron sequences of HLA-B*3818 allele are identical to those of other HLA-B*38 alleles including HLA-B*380101,B*380201 and B*3814.The serological specificity of HLA-B*3818 is B38 and the frequency of this new allele is less than 0.000 5 in Chinese Han population.The parentage analysis showed the haplotype of novel allele is A*030101-Cw*010201-B*3818-DRB1*1312-DOB1*060101.Conclusion The simultaneous mutations in exon and intron were found in the Hovel HLA-B*3818 allele,and so it can present more sequence information for studies and applications associated with HIA genes by analyzing the genomic sequences of novel HLA alleles.

Polymorphism of HLA-A and HLA-B in pre-eclampsia / 北京大学学报(医学版)

Objective: To investigate the association between the polymorphism of HLA-A, HLA-B genes and pre-eclampsia. Methods: HLA-A, HLA-B genotyping was performed by polymerase chain reaction sequence-specific primer (PCR-SSP) in 119 preeclampsia patients, 117 normal pregnant women and their neonates. Results: The study showed that 16 HLA-A and 39 HLA-B alleles were obtained in pre-eclamptic patients and normal pregnant women. 15 HLA-A and 37 HLA-B alleles were obtained in their neonates. No significant difference was found in maternal or neonatal HLA-A, HLA-B alleles be-tween pre-eclampsia group and control group (Pc>0. 05). The frequencies of HLA-A11, HLA-A24,HLA-B13, HLA-B14, HLA-B15, HLA-B52 maternal/fetus genetic assoications were significantly different between pre-eclampsia group and control group (P<0. 05). Conclusion: Some HLA-A, HLA-B maternal/fetus special bindings may be associated with the susceptibility or protective of pre-eclampsia.

Relationship between human leukocyte antigen-A, -B alleles and psoriatic arthritis in Chinese Han population from Shandong Province / 中华皮肤科杂志

with PsA in Chinese Han population from Shandong Province.

The association between HLA-A antigen carrying Bw4 epitope and HIV-1 viral loads and CD+4 T cell counts / 中华检验医学杂志

Objective To investigate the impact of HLA-A antigens carrying Bw4 epitopes on disease course of HIV-1 infection.Methods Three hundred and forty subjects chronically infected with HIV-I were recruited and their HLA-A and B alleles were genotyped with sequence-based high resolution typing assay.HLA-Bw genotypes of these HIV-1 infected subjects were determined and their association with CD+4 T cell counts and viral load were analysed.Results When compared with subjects canting no Bw4 epitopes in HLA-A and HLA-B loci (OBw4) (median of CD+4 T cell counts:294/μ1;plasma viral load median 6.29×104 copies/ml),CD+4 T cell counts in subjects with genotypes of 1Bw4-A and 2Bw4-AA were comparable (307 and 308/μ1,respectively),but higher viral load (1.53×105 and 2.68×105 copies/ml,respectively) was observed.In subjects with Bw4 epitopes in HLA-B alleles but no in HLA-A,significantly higher CD+4 T cell counts (417/μ1,P=0.013) and lower viral load (2.10×104 copies/ml,P=0.007) were observed compared with those without Bw4 in HLA-A and HLA-B.Conclusion HLA-B antigens carrying Bw4 epitope were protective in HIV-1 infection by maintaining higher CD+4 T cell counts and lower viral load,but such protective effect was not observed in HLA-A antigens earring Bw4 epitope.

HLA-B Alleles Associated with Susceptibility or Resistance to Human Immunodeficiency Virus Type 1 in a Xinjiang Uygur Population, China / 中国病毒学

Host genetic factors, such as human leukocyte antigen (HLA) alleles, are important in Human immunod-eficiency virus (HIV) infection and its progression to AIDS. HLA class I genes, especially highly polymorphicHLA-B genes, are involved in the activation of HLA-restricted cytotoxic T lymphocytes (CTLs) against HIV, andthus control susceptibility to or protect against this virus. The present study was aimed to determine the distributionof HLA-B alleles in the Chinese Uygur ethnic group and its association with HIV infection. One hundred ten healthycontrol (HIV negative) and 128 HIV positive Chinese Xinjiang Uygur ethnic individuals were used in this study.HLA typing for B allele was performed by polymerase chain reaction (PCR) with sequence-specific primers (SSP).Hardy-Weinberg equilibrium was calculated using POPGENE software for the healthy control group. The HLA-Bfrequency of each allele was compared between the patients and the controls using the chi-square test. In HIV-1-pos-itive group, gene frequency of allele B * 4901 was significantly higher compared to the healthy control subjects (P=0.02, OR=3.06, 95%CI=1.16～8.10 forB*4901). In contrast, the gene frequency of B * 40 in healthy controlswas significantly higher than in the HIV-positive patients (P=0.02, OR=0.39, 95%CI=0.07～0. 92 for B* 40).In this study, HLA allele B * 4901 may be associated with increased susceptibility to HIV-1 infection, whereas the B* 40 allele may be associated with resistance to H HIV-1 infection.

HLA-B locus genotyping with reference strand mediated conformation analysis (RSCA) system in clinical usage / 中华器官移植杂志

Objective To establish and stabilize a new HLA-B locus typing strategy, reference strand mediated conformation analysis(RSCA)system and to conform its advantages.Methods Of 27 hematopoitic stem cell transplant patients and 63 potential donors DNA samples were extracted from peripheral blood cells and HLA-B loci were both typed by RSCA and PCR-SSP methods. The (ambi)-(guous) results were identified by using DNA sequencing. Results Among 90 samples, 87/90 ((96.7) %) cases could be designated definitely, but one of them was disagreement with the SSP result which was confirmed by sequencing, and 67/90 ((74.4) %) cases could be typed to allelic level. 1/90 ((1.1) %) case could not be identified by RSCA for its bad PCR results. Only one allele of each 2 samples could be designated and the other could not be identified by RSCA, which were further confirmed by sequencing method, and the results confessed which were known as alleles, but there were no corresponding data in RSCA database. Twenty samples were randomly selected to identify the replication rate of RSCA, and the results demonstrated that the replication rate was 100 %. Among PCR-SSP typing results, about 10 % samples might be typed for 1-3 times to confirm their types. Conclusion RSCA had some advantages such as high resolution, high sensitivity, high accuracy, high replication, finding new alleles, large scale and low cost, and was especially suitable for unrelated donor-recipient (screening).

Associations of Moyamoya Patients with HLA Class I and Class II Alleles in the Korean Population

Moyamoya disease is characterized by progressive cerebrovascular occlusion at the peripheral internal carotid artery and development of abnormal collateral circulation at the cerebral basal region. Although abnormal thrombogenesis, inflammation and autoimmune process might be involved in the etiology, the genetic pathogenesis of Moyamoya disease is still unknown. To evaluate the association of Moyamoya disease with HLA alleles in the Korean population, we investigated HLA class I and class II alleles in 28 Moyamoya patients and 198 unrelated healthy controls. The frequency of HLA-B35 allele was significantly increased in the patients compared to the controls (32.1% vs. 10.1%, RR=4.2, p<0.008). Further analysis of HLA-B35 on onset age and sex showed that this allele was significantly increased compared to the controls in both late-onset and female group. Especially, HLA-B35 was the most significantly increased in female of late-onset group compared to the controls. These results suggest that HLA-B35 may be an useful genetic marker for Moyamoya disease, and particularly in females of late onset group in the Korean population.

DNA typing of HLA-B antigens by DNA chip technique / 中华检验医学杂志

Objective To discuss the value of medium resolution typing method for HLA-B antigens of Northern Chinese by DNA chip technique.Methods The chip was made with specific medium distinguish typing probes designed according to gene frequency of HLA-B alleles from Northern Chinese.Unsymmetrical PCR was used to amplify HLA-B exon 2 and 3, then labeled PCR products and hybridize with probes on the chip.Certified the typing of HLA-B by analysed and scanned the signals of hybridize through a set of computer software.Results HLA-B alleles were successfully typed in 30 clinical samples. This medium distinguish probes were able to discern 42 HLA-B alleles from the scope of HLA-B 7~83. Using it we can distinguish B14,73 and 82 three new alleles contrast to PCR-SSP methods.Conclusions DNA typing of HLA-B by chip was proven to be a high-resolution and high-specificity method. It is able to check out the multitudinous samples in one DNA chip and it is more suitable for clinical application.

Distribution of HLA-A, B alleles in patients with Guillain-Barr? syndrome / 中华神经科杂志

Objective To study the relations between the susceptibility to AIDP and AMAN, two forms of Guillain-Barr? syndrome (GBS), and the frequency of HLA-A, B alleles. Methods A case-control research was done in 31 cases of AIDP, 33 cases of AMAN and 132 health individual controls. DNA was extracted from peripheral blood leukocytes by improved fast saltingout. HLA-A, B antigens were typed by DNA-based technology, PCR-sequence specific primers (PCR-SSP) method. In determination of allelic polymorphism by PCR amplification with SSP, oligonucleotide primers are designed to obtain amplification of specific alleles or groups of alleles. Assignment of alleles is based on the presence or absence of PCR amplified product, which may be detected by agarose gel electrophoresis. Results On research of HLA-A, B alleles polymorphism, it showed that HLA-A33 frequency was increased significantly in AIDP patients [22.6% vs 4.5%,corrected probability (Pc)=0.011]; related risk (RR) was 6.1; HLA-B15, B35 frequencies were increased (51.7% vs 20.8%, Pc =0.015; 34.5% vs 6.9%, Pc=0.000 8); RR was 4.1 and 7.1, respectively. Conclusions There are different distribution of HLA-A, B alleles in AIDP and AMAN, two forms of GBS. AIDP susceptibility is associated with HLA-A33, while AMAN is with HLA-B15, B35.