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Journal of Medical Case Reports

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Open Access 01-12-2007 | Case report

Hepatotoxicity induced by horse ATG and reversed by rabbit ATG: a case report

Authors: Khalid A Al-Anazi, Mahmoud D Aljurf, Fahad Z Al-Sharif, Hamad M Al-Omar, Ahmed Alami, Fayyaz Farooq

Published in: Journal of Medical Case Reports | Issue 1/2007

Abstract

Background

The use of antilymphocyte agents has improved patient and graft survival in hematopoietic stem cell and solid organ transplantation but has been associated with the development of short-term toxicities as well as long-term complications.

Case presentation

We report a young female with Fanconi anemia who received antithymocyte globulin as part of the conditioning regimen prior to her planned allogeneic hematopoietic stem cell transplant at King Faisal Specialist Hospital and Research Centre in Riyadh. She developed sudden and severe hepatotoxicity after receiving the first dose of horse antithymocyte globulin, manifested by marked elevation of serum transaminases and mild elevation of serum bilirubin level. Immediately after withdrawal of the offending agent and shifting to the rabbit form of antithymocyte globulin, the gross liver dysfunction started to subside and the hepatic profile results returned to the pre-transplant levels few weeks later. The patient had her allogeneic hematopoietic stem cell transplant as planned without any further hepatic complications. After having a successful allograft, she was discharged from the stem cell transplant unit. During her follow up at the outpatient clinic, the patient remained very well and no major complication was encountered.

Conclusion

Hepatotoxicity related to the utilization of antithymocyte globulin varies considerably in severity and may be transient or long standing. There may be individual or population based susceptibilities to the development of side effects and these adverse reactions may also vary with the choice of the agent used. Encountering adverse effects with one type of antithymocyte agents should not discourage clinicians from shifting to another type in situations where continuation of the drug is vital.

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Michallet M-C, Saltel F, Preville X, Flacher M, Revillard J-P, Genestier L: Cathepsin-B-dependent apoptosis triggered by antithymocyte globulins: a novel mechanism of T-cell depletion. Blood. 2003, 102 (10): 3719-3726. 10.1182/blood-2003-04-1075.CrossRefPubMed

Hanada M, Kishimoto Y, Nakai K, Shimizu T, Matsumoto N, Miyazaki Y, Yamamoto Y, Amakawa R, Fujimoto M, Fukuhara S: Antithymocyte globulin treatment in 11 patients with aplastic anaemia. Rinsho Ketsueki. 2000, 41 (7): 563-567.PubMed

Killick SB, Marsh JCW, Booth JC, Gardon-Smith EC: Liver function abnormality following treatment with antithymocyte globulin for aplastic anaemia. Bone Marrow Transplant. 1997, 19 (3): 249-251. 10.1038/sj.bmt.1700653.CrossRefPubMed

Zimmermann SY, Klingebiel T, Koehl U, Soerensen J, Schwabe D: Tecelac as antithymocyte globulin in conditioning for childhood allogeneic stem cell transplantation. Bone Marrow Transplant. 2002, 29 (12): 957-962. 10.1038/sj.bmt.1703561.CrossRefPubMed

Bacigalupo A: Antilymphocyte/thymocyte globulin for graft versus host disease prophylaxis: efficacy and side effects. Bone Marrow Transplant. 2005, 35 (3): 225-231. 10.1038/sj.bmt.1704758.CrossRefPubMed

Pihusch R, Holler E, Mühlbayer D, Göhring P, Stötzer O, Pihusch M, Hiller E, Kolb H-J: The impact of antithymocyte globulin on short-term toxicity after allogeneic stem cell transplantation. Bone Marrow Transplant. 2002, 30 (6): 347-354. 10.1038/sj.bmt.1703640.CrossRefPubMed

Rossi SJ, Schroeder TJ, Hariharan S, First MR: Prevention and management of the adverse effects associated with immunosuppressive therapy. Drug Saf. 1993, 9 (2): 104-131.CrossRefPubMed

Gluckman E, Auerbach AD, Horowitz MM, Sobocinski KA, Ash RC, Bortin MM, Butturini A, Camitta BM, Champlin RE, Friedrich W, Good RA, Gordon-Smith EC, Harris RE, Klein JP, Ortega JJ, Pasquini R, Ramsay NK, Speck B, Vowels MR, Zhang MJ, Gale PP: Bone marrow transplantation for Fanconi anemia. Blood. 1995, 86 (7): 2856-2862.PubMed

Kohli-Kumar M, Morris C, DeLaat C, Sambrano J, Masterson M, Mueller R, Shahidi NT, YaniK G, Desantes K, Friedman DJ: Bone marrow transplantation in Fanconi anemia using matched sibling donors. Blood. 1994, 84 (6): 2050-2054.PubMed

10.

Maschan AA, Trakhtman PE, Balashov DN, Shipicina IP, Skorobogatova EV, Skvortsova YV, Dyshlevaja ZM, Samochatova EV, Rumiantsev AG: Fludarabine, low-dose busulphan and antithmocyte globulin as conditioning for Fanconi anemia patients receiving bone marrow transplantation from HLA-compatible related donors. Bone Marrow Transplant. 2004, 34 (4): 305-307. 10.1038/sj.bmt.1704580.CrossRefPubMed

11.

Zanis-Neto J, Ribeiro RC, Medeiros C, Andrade RJ, Ogasawara V, Hush M, Magdalena N, Friedrich ML, Bitencourt MA, Bonfim C, Pasquini R: Bone marrow transplantation for patients with Fanconi anemia: a study of 24 cases from a single institution. Bone Marrow Transplant. 1995, 15 (2): 293-298.PubMed

12.

Ayas M, Al-Jefri A, Al-Mahr M, Rifai S, Al-Seraihi A, Tbakhi A, Mustafa M, Khairy A, Mousa E, Igbal A, Shalaby L, El-Solh H: Stem cell transplantation for patients with Fanconi anemia with low-dose cyclophosphamide and anti-thymocyte globulins without the use of radiation therapy. Bone Marrow Transplant. 2005, 35 (5): 463-466. 10.1038/sj.bmt.1704787.CrossRefPubMed

13.

Pawelski S, Rokicka-Milewska R, Oblakowski P, Skwarska E, Takiel M, Karpowicz M, ZdunczyK A, Brodzki LM, Leszko B: ALG/ATG treatment..a useful alternative for BMT in selected aplastic anaemia patients. Folia Haematol Int Mag Klin Morphol Blutforsch. 1984, 116 (3-4): 377-381.

14.

Millar MM, Grammer LC: Case reports of evaluation and desensitization for anti-thymocyte globulin hypersensitivity. Ann Allergy Asthma Immunol. 2000, 85 (4): 311-316.CrossRefPubMed

15.

Steensma DP, Dispenzieri A, Moore SB, Schroeder G, Tefferi A: Antithymocyte globulin has limited efficacy and substantial toxicity in unselected anemic patients with myelodysplastic syndrome. Blood. 2003, 101 (6): 2156-2158. 10.1182/blood-2002-09-2867.CrossRefPubMed

16.

Bielory L, Yancey KB, Young NS, Frank MM, Lawley TJ: Cutaneous manifestations of serum sickness in patients reciving antithymocyte globulin. J Am Acad Dermatol. 1985, 13 (3): 411-417.CrossRefPubMed

17.

Kobayashi R, Kaneda M, Watanabe N, Iguchi A, Cho Y, Yoshida M, Arioka H, Naito H, Shikano T, Ishikawa Y: Adverse effects of anti-thymocyte globulin/anti-lymphocyte globulin therapy. Rinsho Ketsueki. 1999, 40 (7): 531-535.PubMed

18.

Weber M, Kröger N, Langer F, Hansen A, Zabelina T, Eifrig B, Hossfeld OK, Zander AR: Non-overt disseminated intravascular coagulatin in patients during treatment with antitymocyte globulin for unrelated allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant. 2003, 31 (9): 817-822. 10.1038/sj.bmt.1703921.CrossRefPubMed

19.

Ganapiev AA, Abdulkadyrov Kal, Afanas'ev BV: Incidence and characteristics of complication in aplastic anemia patients treated with antilymphocyte globulin. Ter Arkh. 2003, 75 (8): 68-71.PubMed

20.

Mizue N, Watanabe J, Katoh S, Oda T, Suzuki N, Kudoh T: Unrelated bone marrow transplantation in two severe aplastic anemia patients preconditioned with a regimen of cyclophosphamide, antithymocyte globulin and total body irradiation. Rinsho Ketsueki. 1999, 40 (3): 213-217.PubMed

21.

Weimer R, Staak A, Süsal C, Steller S, Yildiz S, Pelzl S, Renner F, Dietrich H, Daniel V, Rainer L, Kamali-Ernst S, Ernst W, Padberg W, Opelz G: ATG induction therapy: long-term effects on Th1 but not Th2 responses. Transpl Int. 2005, 18 (2): 226-236. 10.1111/j.1432-2277.2004.00047.x.CrossRefPubMed

22.

Prin Mathieu C, Renoult E, Kennel De March A, Béné MC, Kessler M, Faure GC: Serum anti-rabbit and anti-horse IgG, IgA and IgM in Kidney transplant recipients. Nephrol Dial Transplant. 1997, 12 (10): 2133-2134. 10.1093/ndt/12.10.2133.CrossRefPubMed

23.

Docloux D, Kazory A, Challier B, Coutet J, Bresson-Vautrin C, Motte G, Thalamy B, Ribibou JM, Chalopin JM: Long-term toxicity of antithymocyte globulin induction may vary with choice of agent: a single-centre retrospective study. Transplantation. 2004, 77 (7): 1024-1033. 10.1097/01.TP.0000119163.30745.C1.CrossRef

24.

Tomas JF, Pinilla I, Garcin-Buey ML, Garcia A, Figuera A, Gomez-Garcia de Soria V, Moreno R, Fernandez-Ranada JM: Long-term liver dysfunction after allogeneic bone marrow transplantation: clinical features and course in 61 patients. Bone Marrow Transplant. 2000, 26 (6): 649-655. 10.1038/sj.bmt.1702532.CrossRefPubMed

Title: Hepatotoxicity induced by horse ATG and reversed by rabbit ATG: a case report
Authors: Khalid A Al-Anazi
Mahmoud D Aljurf
Fahad Z Al-Sharif
Hamad M Al-Omar
Ahmed Alami
Fayyaz Farooq
Publication date: 01-12-2007
Publisher: BioMed Central
Published in: Journal of Medical Case Reports / Issue 1/2007
Electronic ISSN: 1752-1947
DOI: https://doi.org/10.1186/1752-1947-1-35

At a glance: The STEP trials

Springer Medicine

Hepatotoxicity induced by horse ATG and reversed by rabbit ATG: a case report

Abstract

Background

Case presentation

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Case presentation

Conclusion

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