the serum of patient 2 was referred by Dr T. Seaton, Hamilton. General Hospital, Ontario. The editorial assistance of Miss Sarah Underhill is gratefully.
Br.J. Anaesth. (1981), 53, 1173
HEPATIC DAMAGE AFTER EXPOSURE TO HALOTHANE IN MEDICAL PERSONNEL J. NEUBERGER, D. VERGANI, G. MIELI-VERGANI, M. DAVIS AND R. WILLIAMS
SUMMARY
Two surgeons, in whom liver damage developed after occupational exposure to sub-anaesthetic doses of halothane, were found to have a circulating antibody which reacted specifically with halothane-altered hepatocyte membrane components. This antibody has been found previously only in those patients in whom severe hepatic necrosis developed after exposure to halothane and in no other form of liver injury. It may provide a specific diagnostic marker in patients in whom there are other possible causes of liver damage and could, therefore, remove the need for a challenge exposure and its attendant risks.
Although massive hepatocellular necrosis after exposure to halothane is rare (Strunin, 1977), up to 20% of patients have evidence of mild hepatic damage (Trowell, Peto and Cramp ton-Smith, 1975; Wright et al., 1975). There have been a few reports of liver damage developing in medical and paramedical personnel after exposure to subanaesthetic doses of the drug (Belfrage, Ahlgren and Axelson, 1966; Klatskin and Kimberg, 1969; Johnston and Mendelsohn, 1971; Lund, Skulberg and Helle, 1974). The evidence for the association is circumstantial, based on detection of abnormal liver function tests after exposure and exclusion of other causes. In recent studies of the mechanisms of hypersensitivity-induced liver damage, we have shown that patients in whom fulminant hepatic failure develops after multiple exposures to halothane may have a circulating antibody which reacts with a specific halothane-related hepatocyte membrane determinant (Vergani et al., 1980). We describe two medical practitioners in whom hepatic damage developed after occupational exposure to halothane and in whom the antibody was detected.
Seven years before presentation he suffered an episode of acute hepatitis; no cause was found and he recovered completely. Six years later (May 1974), he had a further illness with features similar to hepatitis which resolved after bed-rest. Two months later, after returning to work, an increase in serum glutamic-oxaloacetic transaminase (SGOT) was noted (fig. 1). He was absent from work for 2 months during which the transaminase concentration returned to normal. He returned to work, but again felt unwell and plasma SGOT was found to be increased. He stayed away from work again. Liver biopsy showed a conspicuous mononuclear-cell infiltrate in the portal tracts but without extension to the parenchyma; there was some necrosis of single hepatocytes. This combination resembled unresolved acute hepatitis. Subsequently, after he returned to hospital duties, an increase in SGOT was noted on two occasions, both associated with halothane exposure. The patient was referred to the Liver Unit, King's College Hospital. There was no history of eczema, allergy or exposure to other known hepatotoxins or excess alcohol. On examination, there were no skin signs of chronic liver disease CASE REPORTS and no enlargement of liver or spleen. Hepatitis B Patient 1 surface antigen, antibody, and anticore antibody An Italian surgeon aged 41 yr had been working and specific immunoglobulin M (IgM) to hepatitis for 15yr in operating theatres where he was A virus could not be detected by radioimmunoexposed to both halothane and methoxyflurane. assay and enzyme-linked immunosorbent assay. Antigastric parietal cell antibodies were present in JAMES NBUBERGER, M.A., M.R.C.P.; D. VERGANI, M X>.\ G. MIELIsmall titres (1 in 20). Liver biopsy showed a dense VERGANI, M.D.; M. DAVIS, M.D., M.R.C.P.; ROGER WILLIAMS, MJJ., FJJ.C.P.; Liver Unit, King's College Hospital but well-defined infiltration of the portal tracts by and Medical School, Denmark Hill, London SE5. mononuclear cells which were associated with Correspondence to R. W. some mononuclear cells within the parenchyma.
0007-0912/81/111173-05 801.00
© Macmillan Publishers Ltd 1981
1174
BRITISH JOURNAL OF ANAESTHESIA EXPOSURE
TO
HAI.OTHANF
100.
»0
AUG
1974
1975
FIG. 1. Repeated episodes of "hepatitis" in relation to exposure to halothane (patient 1). Dotted line represents upper limit of normal range of SGOT.
This resembled unresolved hepatitis. The patient performed, at the patient's request. He changed was advised to work only in a halothane-free his specialty to avoid further exposure to haloenvironment and since then he has remained well thane and has remained well since. with a normal serum transaminase concentration. Patient 2 A Canadian doctor aged 26 yr developed a pyrexial illness with increased plasma SGOT after 3 months exposure to halothane. He returned to work but, 1 month later, was admitted to a local hospital with a 5-day history of fever, sore throat and conjunctivitis for which he was given penicillin with no effect. There was no history of exposure to hepatitis or known hepatotoxins. On examination, there was periorbital swelling and conjunctivitis, but there were no skin signs of chronic liver disease and no hepatomegaly. Plasma SGOT on admission was greater than normal (51 iu litre" 1 ) and increased the next day (90 iu litre"'). There was no eosinophilia and serum autoantibodies were not detected. Tests for markers of hepatitis A and B viral infection were negative and antibody titres to Epstein Barr virus and cytomegalovirus were normal. Serum transaminases decreased gradually and were within normal limits 2 months later. Liver biopsy was not
DETECTION OF HALOTHANE- AND METHOXYFLURANERELATED ANTIBODIES
Target hepatocytes were isolated from female New Zealand white rabbits, exposed 18 h previously to either 1% halothane or 1% methoxyflurane and 99% oxygen (Vergani et al., 1980). Antibodies in the serum were detected both by an indirect immunofluorescence technique and a microcytotoxocity assay. Serum was heat-inactivated and absorbed with normal hepatocytes to remove any antibodies reacting with normal liver cell determinants. For immunofluorescence studies, hepatocytes were isolated by mechanical means and incubated with the patient or control serum (diluted 1 in 10) for 30 min. After three washes, the hepatocytes were incubated for a further 30 min with FITC-conjugated anti-human immunoglobulin (diluted 1 in 4). After three more washes, the cells were examined under ultraviolet microscopy. To assay micTOcytotoxicity the hepatocytes were isolated by collagenase digestion and seeded
1175
HEPATIC DAMAGE AFTER HALOTHANE into microculture test wells. Test and control serum diluted 1 in 100 were added to the wells for 2 h to allow any antibody present in the serum to react with specific determinants on the hepatocytes. After the hepatocytes were washed, lymphocytes isolated from normal individuals were added so that antibody-coated hepatocytes could be killed by a subpopulation of the lymphocytes, K cells. After 48 h, the number of viable hepatocytes was counted and the percentage cytotoxicity determined.
TABLE I. % Cytotoxicity induced against treated hepatocytes by serum of patients 1 and 2. Upper limit of normal 29% (mean + 2SD = 15+14). n.t. = Nottested
RESULTS
directly with in vivo effects. Studies have shown the specific antibody response only in those patients in whom severe liver damage has developed after several halothane exposures and not those in whom there has been only a minimal increase in serum transaminase concentrations. Furthermore, this halothane-related antibody has not been detected in the serum of anaesthetists, exposed to halothane, who have normal liver function tests (Davis et al., 1980; Vergani et al., 1980). This is the first report of an association with a relatively minor degree of liver damage. This may be because anaesthetists are exposed to relatively small doses of the drug over a long period of time. Such occupational exposure to halothane has been shown to result in enhanced enzyme induction, as measured by antipyrine clearance (Duvaldestin et al., 1981); in susceptible individuals, this might be enough to enhance halothane biotransformation and generate the halothane-related antigen. The increased frequency and greater severity of liver damage after multiple exposures together with unexplained postoperative pyrexia, arthralgia, eosinophilia, and circulating autoantibodies (including liver-kidney microsomal autoantibodies which are associated with hypersensitivity reactions) are all consistent with an immunologically-mediated hypersensitivity reaction (Walton et al., 1976; Strunin, 1977). The presence of the halothane-related antibody is caused by sensitization to an antigen probably resulting from covalent binding of a halothane metabolite to cellular macromolecules (Neuberger et al., 1980). In both these patients, there was other evidence implicating halothane in the aetiology of recurrent hepatitis. On each occasion the increase in serum transaminase concentrations was closely related to exposure to halothane and the transaminases
Halothane-related antibody was found in the serum of both patients by both methods. Characteristic granular fluorescence was produced by both sera with halothane-treated hepatocytes (fig. 2) and no fluorescence was seen with normal
FIG. 2. Granular immunofluorescence staining pattern produced by serum of patient 2 when reacted with halothanetreated hepatocytes.
hepatocytes. In the cytotoxicity assay, both sera induced significant cytotoxicity to halothanetreated hepatocytes whereas neither did to normal hepatocytes (table I). Methoxyflurane-related antibodies were not found in the serum of patient 1 against methoxyflurane-treated hepatocytes. DISCUSSION
The role of halothane-related antibody in the mechanism of the liver damage following halothane anaesthesia is not known. A direct involvement in the process of hepatic necrosis is suggested by its ability to render halothane-treated hepatocytes susceptible to lysis in the K-cell mediated antibody-dependent cytotoxicity assay in vitro— although in vitro findings cannot be equated
Patient Hepatocytes
1
2
Control Halothane Methoxyflurane
12 48 13
22 38 n.t.
BRITISH JOURNAL OF ANAESTHESIA
1176
TABLE II. Characteristics of reported cases of medical personnel with haloihant-related liver damage, n.r. =• Not recorded; n.t. = not tested; *SMA = smooth muscle antibodies; GPC = gastric parietal cell antibodies
Reference Bclfrage, Ahlgren and Axelson (1966) Klatskin and Kimberg (1969) Johnston and Mendelsohn (1971) Lund, Skulberg Helle (1974) Present report 1 2
Challenge test
Hepatitis virus excluded
n.t.
+ ve
n.t.
+ ve
n.t.
SMA
Posthepatiti* cirrhosis Hepatitis
n.t.
B
n.r.
n.r.
Hepatitis
+ ve
B
-
GPC -
Hepatitis n.t.
n.t. n.t.
A3 A3
Patient age (yr)/ sex
Eczema or allergy
Eosinophilia
32/M
+
+
n.r.
44/M
+
—
n.r.
26/F
—
+
28/F
+
41/M 26/M
-
returned to normal when the patient was no longer in contact with halothane. Liver histology, available in only one patient, was compatible with drug-induced liver injury (Zimmerman, 1978). There have been reports of liver damage in medical and paramedical personnel exposed to sub-anaesthetic doses of halothane (Belfrage, Ahlgren and Axelson, 1966; Klatskin and Kimberg, 1969; Johnston and Mendelsohn, 1971; Lund, Skulberg and Helle, 1974). Hepatitis has also been reported in those who have abused halothane (Schatzki, Kay and Dickinson, 1973); Kaplan et al., 1979) although they may have been exposed to much greater doses of halothane. Of the former group, three had a history of allergy or eczema, two had peripheral eosinophilia, and one had serum autoantibodies (table II). Liver histology showed a hepatitis which progressed in one patient to cirrhosis. Other causes of liver damage, especially A and B viral hepatitis, were not always excluded. If a patient is thought to be sensitive to halothane, it is possible to ensure that he is not exposed to it again. It is much more difficult for an anaesthetist. In practice, it may mean a change in his work. Therefore every effort should be made to determine whether or not a person is sensitized to halothane. Controlled re-exposure would put a patient already sensitized at serious risk of developing potentially fatal hepatic necrosis. Furthermore, an increase in serum transaminase concentration may indicate only that halothane is exacerbating pre-existing liver disease. By providing a specific marker of sensitization, the
Autoantibodies*
Liver histology
halothane-related antibody obviates the need for a challenge test. ACKNOWLEDGEMENTS
This work forms part of a study of the mechanisms of drug hepatotoxicity generously supported by Ciba-Geigy Uk Ltd. the serum of patient 2 was referred by Dr T. Seaton, Hamilton General Hospital, Ontario. The editorial assistance of Miss Sarah Underhill is gratefully acknowledged. REFERENCES
Belfrage, S., Ahlgren, I., and Axelson, S. (1966). Halothane hepatitis in an anaesthetist. Lancet, 2, 1466. Davis, M., Eddleston, A. L. W. F., Neuberger, J., MieliVergani, G., Vergani, D., and Williams, R. (1980). Halothane hepatitis. N. Engl.J. Med., 303, 1123. Duvaldestin, P., Mazze, R. I., Nivoche, Y., and Desmonts, J. M. (1981). Occupational exposure to halothane results in enzyme induction in anesthetists. Anesthesiology, 54, 57. Johnston, C. I., and Mendelsohn, F. (1971). Halothane hepatitis in a laboratory technician. Aust. N.Z.J. Med., 2,171. Kaplan, H. G., Bakkcn, J., Quadracci, L., and Schubach, W. (1979). Hepatitis caused by halothane sniffing. Ann. Intern. Med., 90, 797. Klatskin, G., and Kimberg, D. V. (1969). Recurrent hepatitis attributable to halothane sensitisation in an anesthetist. N. Engl.J. Med., 280, 515. Lund, I., Skulberg, A., and Helle, I. (1974). Occupational hazard of halothane. Lancet, 2, 328. Neuberger, J., Mieli-Vergani, G., Tredger, M. J., Davis, M., and Williams, R. (1980). Oxidative metabolism of halothane in the immunopathogenesis of the associated liver damage. Gut, 20, A467. Schatzki, P. F., Kay, S., and Dickinson, McGavic, J. (1973). Ultrastructural pathology of a case of halothane hepatitis. Am. J. Dig. Dis., 18, 905. Strunin, L.(1977). The Liver and Anaesthesia, p. 166. London: W. B. Saunders.
HEPATIC DAMAGE AFTER HALOTHANE Trowell, J., Peto, R., and Crampton-Smith, A. (1975). Controlled trial of repeated halothane anaesthetics in patients with carcinoma of the uterine cervix treated with radium. Lancet, 1, 821. Vergani, D., Mieli-Vergani, G., Alberti, A., Neuberger, J., Eddleston, A. L. W. F., Davis, M., and Williams, R. (1980). Antibodies to the surface of halothane-altered rabbit hepatocytes in patients with severe halothaneassociated hepatitis. N. Engl. J. Med., 303, 66. Walton, B., Simpson, R. R., Strunin, L., Doniach, D., Perrin, J., and Appleyard, A. J. (1976). Unexplained hepatitis following halothane. Br. Med. J., 1, 1171. Wright, R., Eade, O. E., Chisholm, H., Hawsley, M., Lloyd, B., Moles, T. M., Edwards, J. C , and Gardner, M. J. (1975). Controlled prospective study on the effect on liver function of multiple exposures to halothane. Lancet, 1,817. Zimmerman, H. J. (1978). Hepatotoxicity. New York: Appleton Century Crofts.
1177 LEBERSCHADEN BEI MEDIZINISCHEM PERSONAL NACH AUSGESETZTSEIN AN HALOTHAN ZUSAMMENFASSUNG
Bei zwei Chirurgen, bei denen Leberschaden nach berufsbedingtem Ausgesetztsein an Subanasthesie-Dosen von Halothan auftraten, wurden kreisende Antikorper gefunden, die spezjfisch mit halothanveranderten Hepatozytmembranbestandteilen reagierten. Dieser Antikdper ist bis jetzt nur bei Patienten gefunden worden, bei denen eine schwere Lebemekrose nach Ausgesetztsein an Halothan auftrat, und bei keiner anderen Form von Leberschaden. Er konnte einen spezifischen Hinweis bei Patienten geben, bei denen andere Ursachen vorliegen konnten und somit die Notwendigkeit eines herausfordernden Aussetzen und die damn verbundenen Gefahren vermeiden. DANO HEPATICO EN EL PERSONAL MEDICO DESPUES DE SU EXPOSICION AL HALOTANO
LESION HEPATIQUE APRES EXPOSITION D U PERSONNEL MEDICAL A L'HALOTHANE RESUME
On a trouvc que deux chirurgiens souffraient d'une lesion hepatique consecutive a lew exposition professionnelle a des doses non anesthesiantes d'halothane et qu'ils avaient dans leur circulation sanguine un anticorps qui reagissait specifiquement aux composants de la membrane dTiepatocytes modifies par 1'haJothane. On n'avait precedemment trouve cet anticorps que chez les patients sur lesquels une necrose hepatique grave s'etait developpee apres exposition a l'halothanc, mais dans aucune autre forme de lesion du foie. II peut constituer vin facteur d'identifkation specifique de diagnostic chez les patients ayant d'autres causes possibles de lesion du foie et pourrait, done, eliminer la necessite d'une exposition d'epreuve avec tous les risques que cela comporte.
SUMAJUO
Se averiquo que dos cirujanos que habian desarrollado complicaciones en el higado despues de su exposition a dosis subanestesicas de halotano, como consecuencia de sus actividades profesionales, presentaban un anticuerpo en drculacion que reaccionaba de forma especifica con los componentes de la membrana hepatocitica que habian sufrido alteracion a causa de dicho halotano. Este antjeuerpo se habia encontrado anteriormente solo en aquellos pacientes en los que se desarrollo una necrosis heparica aguda despues de su exposicion al halotano, no habiendose presentado en ningun otro tipo de complicacion heparica. Puede que esto provea un indicador especifico para efectuar diagnosricos en aquellos pacientes en los que, seguramente, las complicadones hepaticas tengan otro tipo de causas y, por lo tanto, podia hacer innecesaria la exposicion de prueba y sus riegos congenitos.
