Hairdye-Induced Hepatitis: An Unusal Cause of Acute Hepatitis

Sir, 
 
We present an unusual case of acute hepatitis caused by hair dye. 
 
Hair dye contains various mutagenic and carcinogenic chemicals and is examined as a risk factor for various malignancies. Hair dye-induced hepatitis is a rare condition. There is only one case of hair dye-induced hepatitis reported in the literature.[1] 
 
A 33-year-old healthy young female presented with pruritus, skin lesions and jaundice 2 days after using a new hair dye rather than her usual one. Clinically, she was febrile, icteric, with hepatosplenomegaly but no ascites. Laboratory investigations showed hypereosinophilia of 20%, abnormal liver profile with total bilirubin of 13.5 mg/dL, conjugated 6.8 mg/dL, alanine transaminase 190 IU/L, aspartate transminase 152 IU/L, alkaline phosphatase of 227 IU/L and albumin being 3.7 g/dL. An ultrasound of the abdomen showed features of acute hepatitis and a normal biliary system. The prothrombin time was normal. 
 
Work-up for acute hepatitis indicated negative IgM antibody for hepatites A, E, and anti-HBc antibody. Additionally, hepatitis B virus DNA was undetectable. Serology for cytomegalovirus, Herpes simplex virus, Epstein barr virus, leptospira and malaria were negative. Wilson's and autoimmune markers were also negative. Drug-induced hepatitis was considered in view of chronology of events. Because the patient had an allergic reaction, lymphocyte activation test was performed to study if the hair dye in question induced immune-mediated drug reaction leading to acute hepatitis. 
 
Lymphocytes were isolated using Histopaque, 1077 (Sigma-Aldrich, St.louis, USA) by centrifugation.[2] Lymphocytes from a normal person and from a patient were subjected to hair dye exposure. Control was patient lymphocytes without hair dye. Suspension from the reaction mixture was taken out at different intervals and smears were examined for lymphocyte reactivity and adenosine deaminase (ADA) level represent lymphocyte activation. At the end of 60 min, 70% and at the second hour, 90% of the lymphocytes were activated as against the normal lymphocytes with no reactivity and only 3% of the controls. The ADA levels increased by 20% and 30% by the end of the first and second hour, respectively. Results obtained in this in vitro lymphocyte activity experiment strongly suggest that hair dye causes immune-mediated drug reaction in hypersensitive individuals [Figure 1]. 
 
 
 
Figure 1 
 
All reactive lymphocytes after 20 hours of incubation (oil immersion pictures) 
 
 
 
Hair dye is a well-recognized cause of contact dermatitis. Routinely used hair dyes contain multiple components viz Toluene-2, 5-diamine, resorcin, cetearyl alcohol, polyethylene glycol, etc. Chemicals of the hair dye can be absorbed into the body through a wound, damaged skin or by aspiration of the spray during dyeing. The pathogenesis of drug-induced hepatotoxicity usually involves either the parent drug or its metabolite, which affects the hepatocytes directly or elicits an immune response.[3] 
 
The chronological course of the present patient, allergic skin manifestations and in vitro lymphocyte reactivity to hair dye supported hair dye-induced immune-mediated hepatitis.[4] Liver biopsy was not performed as investigations supported diagnosis and her liver functions improved after 2 weeks of cessation of hair dye. 
 
Thus, the present case suggests a possible role of hair dye in inducing an immune-mediated drug reaction in hypersensitive individuals and a lymphocyte activation test may be utilized to diagnose the immune-mediated drug-induced hepatotoxicity.

Gastric carcinoma is a frequent tumor, especially in some parts of the world like Japan. Metastasis to the bone from gastric tumors is rare and has been estimated to appear in 13.4% of the autopsy cases of gastric carcinoma in a Japenese study. [1] It mainly affects patients with poorly differentiated tumors and widespread disease along with metastasis to other sites. However, there have been reports of bony metastasis from early gastric cancer. Metastasis to the bone can occasionally be the first manifestation of gastric tumor, [2] but have only rarely been described as a sole manifestation of tumor recurrence. [3] Skeletal metastatic lesions arising from gastric cancer are uncommon and usually of osteolytic type. The thoracic and lumbar vertebrae are the most frequent sites [2] although there have been occasional reports of metastasis to the calcaneal bone, [3] pelvis, and even the skull base. Metastasis to femur is very rare. [2,3] Radioisotope bone imaging is generally accepted as being the initial procedure of choice in search for bone metastasis. Roentgenographic evaluation for bone metastasis has limited value because symptoms from bone metastasis frequently occur before any radiological abnormality becomes evident.
Prognosis of patients with osseous metastasis from gastric cancer seem to be dismal (median survival time 5 months) and 3.5 years has been the longest survival period reported in the literature. Radiotherapy has been advocated as the best therapeutic alternative for pain control with a response rate of 75%. [4] However, recent reports have employed chemotherapy with 5-FU with no adverse side effects. Nevertheless, prognosis remains poor and therapy is mainly aimed at relieving pain and discomfort.

Hairdye-Induced Hepatitis: An Unusal Cause of Acute Hepatitis
Sir, We present an unusual case of acute hepatitis caused by hair dye.
Hair dye contains various mutagenic and carcinogenic chemicals and is examined as a risk factor for various malignancies. Hair dye-induced hepatitis is a rare condition. There is only one case of hair dye-induced hepatitis reported in the literature. [1] A 33-year-old healthy young female presented with pruritus, skin lesions and jaundice 2 days after using a new hair dye rather than her usual one. Clinically, she was febrile, icteric, with hepatosplenomegaly but no ascites. Laboratory investigations showed hypereosinophilia of 20%, abnormal liver profile with total bilirubin of 13.5 mg/dL, conjugated 6.8 mg/dL, alanine transaminase 190 IU/L, aspartate transminase 152 IU/L, alkaline phosphatase of 227 IU/L and albumin being 3.7 g/dL. An ultrasound of the abdomen showed features of acute hepatitis and a normal biliary system. The prothrombin time was normal.
Work-up for acute hepatitis indicated negative IgM antibody for hepatites A, E, and anti-HBc antibody. Additionally, hepatitis B virus DNA was undetectable. Serology for cytomegalovirus, Herpes simplex virus, Epstein barr virus, leptospira and malaria were negative. Wilson's and autoimmune markers were also negative. Drug-induced hepatitis was considered in view of chronology of events. Because the patient had an allergic reaction, lymphocyte activation test was performed to study Letters to the Editor Letters to the Editor if the hair dye in question induced immune-mediated drug reaction leading to acute hepatitis.
Lymphocytes were isolated using Histopaque, 1077 (Sigma-Aldrich, St.louis, USA) by centrifugation. [2] Lymphocytes from a normal person and from a patient were subjected to hair dye exposure. Control was patient lymphocytes without hair dye. Suspension from the reaction mixture was taken out at different intervals and smears were examined for lymphocyte reactivity and adenosine deaminase (ADA) level represent lymphocyte activation. At the end of 60 min, 70% and at the second hour, 90% of the lymphocytes were activated as against the normal lymphocytes with no reactivity and only 3% of the controls. The ADA levels increased by 20% and 30% by the end of the first and second hour, respectively. Results obtained in this in vitro lymphocyte activity experiment strongly suggest that hair dye causes immune-mediated drug reaction in hypersensitive individuals [ Figure 1].
Hair dye is a well-recognized cause of contact dermatitis. Routinely used hair dyes contain multiple components viz Toluene-2, 5-diamine, resorcin, cetearyl alcohol, polyethylene glycol, etc. Chemicals of the hair dye can be absorbed into the body through a wound, damaged skin or by aspiration of the spray during dyeing. The pathogenesis of drug-induced hepatotoxicity usually involves either the parent drug or its metabolite, which affects the hepatocytes directly or elicits an immune response. [3] The chronological course of the present patient, allergic skin manifestations and in vitro lymphocyte reactivity to hair dye supported hair dye-induced immune-mediated hepatitis. [4] Liver biopsy was not performed as investigations supported diagnosis and her liver functions improved after 2 weeks of cessation of hair dye.
Thus, the present case suggests a possible role of hair dye in inducing an immune-mediated drug reaction in hypersensitive individuals and a lymphocyte activation test may be utilized to diagnose the immune-mediated druginduced hepatotoxicity.