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Mononucleosis and hepatic failure associated with diphenylhydantoin treatment in an infant
1Department of Pediatrics, National Taiwan University Hospital, Taipei, R.O.C.
Insights
This case report details a rare instance of diphenylhydantoin-induced liver failure and a mononucleosis-like illness in a 6-month-old infant. Prompt supportive care and exchange transfusions were crucial for recovery.
Area of Science:
- Pediatric Hepatology
- Clinical Toxicology
- Drug-Induced Liver Injury
Background:
- Diphenylhydantoin (phenytoin) is an anticonvulsant medication.
- Drug-induced liver injury and infectious mononucleosis are uncommon in children.
- Hepatic failure following these conditions in the same individual is exceptionally rare, particularly in infants.
Observation:
- A 6-month-old infant developed a mononucleosis-like syndrome and hepatic failure 16 days after diphenylhydantoin administration for seizure control.
- Initial symptoms included fever, rash, hepatosplenomegaly, lymphadenopathy, and atypical lymphocytosis, mimicking infectious mononucleosis.
- Negative heterophil antibody and viral studies (Epstein-Barr virus, cytomegalovirus, hepatitis B virus) ruled out infectious causes.
Findings:
- The infant presented with progressive jaundice and shrinking liver size, indicative of severe hepatic dysfunction.
- Histologic examination of liver biopsies revealed significant hepatic parenchymal loss, cholestasis, fatty change, and portal fibrosis.
- The patient experienced stage I hepatic coma but recovered with supportive care and exchange transfusions.
Implications:
- This case highlights the potential for diphenylhydantoin to cause severe, acute liver injury mimicking infectious mononucleosis in infants.
- It underscores the importance of considering drug-induced etiologies in pediatric cases of hepatitis with atypical presentations.
- Early recognition and aggressive supportive management, including exchange transfusions, may be critical for survival in severe drug-induced hepatic failure.
Abstract:
Diphenylhydantoin-induced hepatitis and mononucleosis are uncommon in children. The occurrence of these two diseases in the same individual, with progression to hepatic failure is rare and has not been reported in infants. This report represents a 6-month-old male infant who developed an infectious mononucleosis-like syndrome and hepatic failure 16 days after diphenylhydantoin administration. He took this anticonvulsant for controlling seizures after a head injury. Fever, skin rash, hepatosplenomegaly, lymphadenopathy, and atypical lymphocytosis led to the initial diagnosis of infectious mononucleosis. However, negative heterophil antibody did not support the diagnosis. Jaundice ensued in the following course and became more and more profound. Meanwhile, physical examination showed shrinking in liver size. Negative virology studies, including Epstein-Barr virus, cytomegalovirus, and hepatitis B virus, excluded them as causative agents. The patient lapsed into a stage I hepatic coma, but gradually recovered clinically and biochemically after eight successive exchange transfusions and supportive care. Two liver biopsies were performed 20 and 50 days after the onset of disease, respectively. Remarkable hepatic parenchymal loss, cholestasis, and fatty change were found on histologic examination of the first biopsy specimen, and portal fibrosis was noted on the second.