RESUMO
Phenobarbital continues to be widely used in childhood epilepsy. Incorrect drug prescription can sometimes lead to intoxication, particularly in young children. A 40-month-old female infant presented to our emergency department due to failure to awaken. The patient was assessed in terms of etiology of coma, and her history revealed that she had been given a 100 mg phenobarbital pill instead of 15 mg. Her blood phenobarbital level was high (>80 mg/dl). At physical examination, her Glasgow coma score was 6, the pupils were isochoric, pupillary light reflex was bilateral positive, deep tendon reflexes were absent, respiration was superficial, and pulmonary bilateral diffuse secretory rales were present, and the patient was intubated. Continuous venovenous hemodiafiltration (CVVHDF) was performed due to prolonged coma, intubation, and potentially fatal phenobarbital level. Blood phenobarbital levels at 4 and 12 h improved to >80 and 33.4 mg/dl, and the patient was extubated at 14 h. CVVHDF was effective in intoxication despite long-acting barbiturate phenobarbital not binding to protein. We think that this is a useful method capable of use in phenobarbital intoxications.
RESUMO
Hepatitis A is a common cause of acute hepatitis throughout the world and is usually a mild self-limiting disease of the liver, but rarely presents as fulminant hepatitis in 0.14-0.35% of acute hepatitis A. Acute renal failure requiring dialysis in acute hepatitis A is also exceeding rare. We here report an unusual case of acute renal failure associated with acute fulminant hepatitis A. A previously healthy 22-year-old female was admitted to our hospital with nausea and vomiting of 1 day duration. Biochemical tests on admission revealed a marked increase of serum AST 19,810 IU/L, ALT 10,340 IU/L, total bilirubin 5.7 mg/dL, BUN 32.7 mg/dL and creatinine 4.4 mg/dL. Prothrombin time was prolonged to 40.3 seconds (INR 5.85). Random urine Na+ was 121.5 mmol/L and fractional excretion of sodium 22%. IgM antibody to hepatitis A virus was positive, while serology tests for hepatitis B and C virus, HIV, cytomegalovirus and Epstein-Barr virus were negative. On the 4th day of admission, hepatic encephalopathy and diuretics-resistant pulmonary edema developed. Lactulose treatment was performed for hepatic encephalopathy, and intermittent hemodialysis and continuous venovenous hemodialysis for pulmonary edema and uremia. On day 21, her urine output increased up to 1,000 cc with progressive improvement in renal function. She was discharged on day 32, with her serum creatinine of 2.0 mg/dL and total bilirubin of 4.7 mg/dL.