title: Nimesulide-induced fatal acute liver failure in an elderly woman with metastatic biliary adenocarcinoma. A case report.
abstract: BACKGROUND
  Nimesulide is a selective inhibitor of the enzyme cyclooxygenase 2. Although considered to be a safe drug, cases of acute hepatitis and fulminant liver failure have been reported in Europe, the United States and South America, especially among elderly female patients. Until now, there had not been any reports in the literature relating to Brazilian subjects.
  
  
  METHODS
  An 81-year old female who had been using nimesulide therapy for six days presented hematemesis and epistaxis two days before hospitalization. Clinical examination showed an extensive coagulation disorder, diffuse hematomas, hypotension and tachypnea. Laboratory tests revealed abnormalities in coagulation tests; leukocytosis; reduced platelet, hemoglobin and red blood cell counts; and elevated direct bilirubin, serum aspartate transaminase (AST), gamma-glutamyl transpeptidase (GGT), alkaline phosphatase and renal function biomarkers. Hepatitis B and C tests were not reactive. Carcinoembryonic antigen (CEA), CA-19-9 and CA-125 levels were increased by, respectively, 1,000, 10,000 and 13 fold, whereas the alpha-fetoprotein level was normal, thus indicating a malignant tumor in the bile duct that did not originate from the liver. Thirty-six hours after hospitalization, the patient's condition worsened, leading to death. The necropsy findings included acute hepatitis with hepatocellular collapse, as well as metastasis of a carcinoma, probably from the bile duct.
  
  
  CONCLUSIONS
  Despite the carcinoma presented by the patient, nimesulide use may have contributed towards the fatal acute liver failure. Until this issue has been clarified, caution is required in prescribing nimesulide for liver disease patients.
authors.affiliation: Department of General Pathology, Universidade Estadual de Londrina (UEL), Londrina, Paraná, Brazil.
authors.forename: Sara Santos
authors.initials: SS
authors.lastname: Bernardes
authors.affiliation: Universidade Estadual de Londrina (UEL), Londrina, Paraná, Brazil.
authors.forename: André
authors.initials: A
authors.lastname: Souza-Nogueira
authors.affiliation: Department of Physiological Sciences, Universidade Estadual de Londrina (UEL), Londrina, Paraná, Brazil.
authors.forename: Estefânia Gastaldello
authors.initials: EG
authors.lastname: Moreira
authors.affiliation: Department of Clinical Medicine, University Hospital, Universidade Estadual de Londrina (UEL), Londrina, Paraná, Brazil.
authors.forename: Marina Okuyama
authors.initials: MO
authors.lastname: Kishima
authors.affiliation: Department of Clinical Medicine, University Hospital, Universidade Estadual de Londrina (UEL), Londrina, Paraná, Brazil.
authors.forename: Alda Fiorina Maria Losi
authors.initials: AF
authors.lastname: Guembarovski
authors.affiliation: Department of Clinical Medicine, University Hospital, Universidade Estadual de Londrina (UEL), Londrina, Paraná, Brazil.
authors.forename: Tercilio Luiz
authors.initials: TL
authors.lastname: Turini
authors.affiliation: Department of Pathology, Clinical and Toxicology Analysis, Universidade Estadual de Londrina (UEL), Londrina, Paraná, Brazil.
authors.forename: Conceição Aparecida
authors.initials: CA
authors.lastname: Turini
mesh_terms: D000230:Adenocarcinoma / Q000556:secondary*; D000369:Aged, 80 and over; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects*; D056486:Chemical and Drug Induced Liver Injury / Q000473:pathology; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D017114:Liver Failure, Acute / Q000139:chemically induced* / Q000473:pathology; D008113:Liver Neoplasms / Q000473:pathology*; D013449:Sulfonamides / Q000009:adverse effects*
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D013449:Sulfonamides; C012655:nimesulide