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Medical Assistant Emergency Department Rimini Hospital Via Parmense 18 47900 Rimini, Italy strocchi{at}med.unibo.it
Medical Assistant Internal Medicine Department Rimini Hospital
Medical Assistant Emergency Department Rimini Hospital
Published Online, April 20, 2004. www.theannals.com, DOI 10.1345/aph.1D582
Case Report. A 77-year-old white man diagnosed with mild hepatitis C virus–related chronic liver disease, hypertension, and depression was admitted to the emergency department because he had taken 28 tablets of telmisartan 80 mg and 20 tablets of oxazepam 30 mg 8 hours earlier. On admission, he reported only mild and transient abdominal pain, and his wife observed that he had slept all afternoon. The patient exhibited a depressed mood without impairment of cognitive function or signs of neurologic deficits.
Physical examination was unremarkable, and vital signs were stable except
for blood pressure 90/65 mm Hg; electrocardiogram and chest X-ray were normal.
Baseline laboratory investigations showed normal levels of leukocytes,
aspartate aminotransferase, alanine aminotransferase,
-glutamyltransferase, triglycerides, creatinine, and electrolytes, but
a marked increase of amylase blood levels
(Table 1). The patient denied
past or recent alcohol abuse or abdominal trauma, and an ultrasound ruled out
gallstones and biliary tract or pancreatic abnormalities. Normal results from
a routine biochemistry evaluation, performed 10 days before, excluded other
diseases.
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The patient was admitted, and activated charcoal 30 g and magnesium sulfate 30 g were immediately administered, but a gastric lavage was not performed because of the time that had passed since drug ingestion. Hypotension was treated with intravenous fluids. An infusion of gabexate mesilate 900 mg/day was started and continued for 3 days. Subsequent laboratory investigations were negative for autoantibodies or signs of hyperparathyroidism. The patient remained asymptomatic, and the biochemical alterations were normal at discharge (3 days later).
Discussion. Drugs are a rare cause of acute pancreatic injury, and only a few cases have been reported with standard doses of losartan and irbesartan; the occurrence of mild pancreatitis also after telmisartan overdose further suggests a rare class effect. The renin–angiotensin system is present in pancreatic tissues, but the mechanism of this adverse reaction is still unclear.2-4 The patient was not taking other drugs, and the concomitant overdose of oxazepam was not considered responsible because it has never been associated with cases of pancreatic injury, despite its widespread use. Based on the available data and the Naranjo probability scale, the likelihood that this adverse reaction was caused by telmisartan could be rated probable.5
References
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