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Co-amoxiclav jaundice: clinical and histological features and HLA class II association
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  1. J O'Donohuea,
  2. K A Oienb,
  3. P Donaldsonc,
  4. J Underhillc,
  5. M Clarec,
  6. R N M MacSweenb,
  7. P R Millsa
  1. aDepartment of Gastroenterology, Gartnavel General Hospital, Glasgow G12 0YN, UK, bUniversity Department of Pathology, Western Infirmary, Glasgow G11 6NT, UK, cInstitute of Liver Studies, King's College Hospital, London SE5 9RS, UK
  1. Dr J O'Donohue, University Hospital Lewisham, London SE13 6LH, UK. Email: john.o'donohue{at}uhl.nhs.uk

Abstract

BACKGROUND AND AIMS Jaundice associated with co-amoxiclav has been increasingly recognised. We aimed to characterise its clinical and histological features and to investigate linkage with human leucocyte antigen class II haplotypes.

METHODS We identified cases in the west of Scotland in the period 1991–1997 and performed polymerase chain reaction amplification and oligonucleotide probing on whole blood.

RESULTS Twenty two cases were identified (10 male, mean age 59.1 years). Jaundice occurred a median of 17 days after drug commencement, with a median peak bilirubin level of 225 μmol/l (range 84–598) and median duration of jaundice 69 days (range 29–150). Two patients had primary biliary cirrhosis and two other patients had persistently abnormal liver biochemistry on follow up. One death occurred in a frail elderly woman despite resolving jaundice. The frequency of jaundice was 1 in 78 209 co-amoxiclav prescriptions. Liver biopsy, available in 12 patients, showed perivenular bilirubinostasis, accompanying reactive ceroid laden macrophages, and portal inflammation with focal injury to interlobular bile ducts. Fourteen of 20 patients had DRB1*1501 compared with 27 of 134 controls (p<2.5×10–6; odds ratio (OR) 9.25; relative risk (RR) 6.43). Of these, seven patients were homozygous for DRB1*1501(p< 10–8; OR 35.54; RR=8.68) compared with two of 134 controls. All patients with DRB1*1501 had the extended haplotype DRB1*1501-DRB5*0101-DQA1*0102-DQB1*0602. There were no clinical or histological differences between genotypes.

CONCLUSIONS Co-amoxiclav associated hepatotoxicity may have a genetic basis and be delayed, severe, and prolonged, although complete recovery is usual.

  • co-amoxiclav
  • jaundice
  • human leucocyte antigen

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Footnotes

  • Abbreviations used in this paper:
    HLA
    human leucocyte antigen
    PBC
    primary biliary cirrhosis
    OR
    odds ratio
    RR
    relative risk

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