Novel risk factors and early detection of anti tubercular treatment induced liver injury-Looking beyond American Thoracic Society Guidelines.

INTRODUCTION: ATT remains the standard treatment for tuberculosis. Drug-induced liver injury (DILI) has been a long-standing concern in the treatment of tuberculosis (TB) infection. AIMS AND OBJECTIVES: To study the occurrence and risk factors of DILI in patients on ATT by regular clinical and biochemical monitoring. MATERIALS AND METHODS: 200 patients, in whom ATT was started, were enrolled in the study. None of the patients with established risk factor for DILI as recognized by ATS guidelines was included in our study population. Regular clinical and liver function test monitoring was done at the commencement of ATT and then at 2, 4, and 8 weeks in the intensive phase subsequently at 4 and 6 months. RESULTS: DILI developed in 16 patients. Among those, 10 patients (62.5%) developed early DILI and 6 patients (37.5%) developed late DILI. Female gender and extrapulmonary tuberculosis were found to be associated with increased risk of ATT-induced DILI, whereas age, BMI, and serum albumin were not found to significantly increase DILI risk. CONCLUSION: DILI is a common problem among patients on ATT in our population. Early detection not only reduces the risk of developing Hepatic Failure but also prevents mortality.

The diagnostic efficacy of adenosine deaminase in tubercular effusion.

OBJECTIVE: This study aims to evaluate the diagnostic efficacy of adenosine deaminase in tubercular effusions. METHODS: This study was conducted at the Department of General Medicine and Cardiovascular and Thoracic Surgery, SKIMS, for a period of two years between November 2008 and November 2010. A total of 57 patients presenting with pleural effusions during the two-year study period, who presented with clinical manifestations suggestive of tuberculosis (i.e., the presence of productive cough, low-grade fever, night sweats, weight loss, and chest pain, especially if these symptoms last (3)4 weeks) were included in the study. If the patients presented with less than two of these symptoms, and especially if the clinical manifestations were of <4 weeks duration, they were excluded from the study. RESULTS: The mean adenosine deaminase activity level in all the 57 patients was 109 U/L while the mean adenosine deaminase activity levels in pleural TB patients was 80 U/, and 64 U/L in the controls (p=0.381). Considering 40 U/L as the cut off, the results were positive in 35 out of 39 tuberculosis patients and 9 out of 18 controls. The sensitivity of adenosine deaminase for tubercular effusions worked out to be 90%, with only 50% specificity. CONCLUSION: This study suggests that the estimation of adenosine deaminase activity in pleural fluid is a rapid diagnostic tool for differentiation of tubercular and non tubercular-effusions. The sensitivity and specificity of adenosine deaminase for tubercular effusions in this study was 90% and 50% respectively.

Systemic lupus erythematosus with distal renal tubular acidosis presenting as hypokalemic paralysis with respiratory failure.

An eighteen-year-old woman presented with hypokalemic respiratory failure. She was found to have distal renal tubular acidosis (dRTA) as the underlying cause for hypokalemia. This was treated successfully, and no apparent etiology for the dRTA was discovered. Three years later she presented with full-blown picture of systemic lupus erythematosus (SLE) together with features of persistent dRTA complicated, this time, with bilateral renal calculi and nephrocalcinosis. It is very likely that the dRTA was an early feature that preceded the other markers of SLE. The moral of this case is that patients with dRTA should be followed-up carefully as a primary cause for the dRTA may show up in-due-course and to monitor the treatment so as to prevent long-term complications of the RTA.