Gross oedema occurring during treatment for depression.

Abstract

Cirrhosis and haemolysis complicating methyldopa treatmentHaemolysis is a recognised complication of methyldopa treatment.' Chronic hepatitis may also be induced by methyldopa and progress to cirrhosis if the drug is continued.2 We describe here a patient who developed severe haemolytic anaemia after two years on methyldopa and was also found to have active cirrhosis. Case reportA 68-year-old English woman had suffered from psoriasis for many years. It was usually mild and had needed intermittent treatment with various topical ointments, including betamethasone. A severe exacerbation had occurred four years before admission and had responded to an 11-month course of oral prednisolone. She had never taken methotrexate. Twenty-six months before admission she had presented with symptoms and signs of right and left ventricular failure and had been found to have a blood pressure of 200/120 mm Hg.Treatment-She had responded rapidly to treatment with methyldopa, 1 5 g/day, frusemide 40 mg,/day, and digoxin 0 25 mg day. Four months later an acute generalised eczematous reaction had occurred. All drugs had been stopped for three weeks but the rash had persisted and her heart failure rapidly become more severe. Treatment had been restarted with the same drugs in the same doses. The rash had responded rapidly to topical fluocinonide, and she had left hospital much improved 11 days later. She had taken the methyldopa, frusemide, and digoxin regularly during the next 21 months, and had remained reasonably well and active until the onset of jaundice.She had never drunk alcohol regularly or heavily. No relevant family history was known. Adverse effect-The patient was admitted complaining of jaundice, itching, and malaise, which had increased over three weeks. She was short of breath on slight exertion; her ankles and legs had become swollen; and her motions were loose, pale, and offensive. Mental confusion was noticed on admission, and this rapidly became severe. Examination showed moderate jaundice, anaemia, purpura on both arms, and pitting oedema to waist level. Both legs showed psoriatic patches and scratch marks. The pulse rate was 56 beats/ min, blood pressure 130/70 nmm Hg, and the central venous pressure was 8 cm above the manubriosternal angle. The heart was dilated and abundant moist sounds were heard at both lung bases. The liver was enlarged 12 cm below the rib-margin, tender, hard and irregular. The spleen could not be felt. Ascites was suspected but the signs were obscured.Investigations The cause of the mental confusion is obscure. Once established it changed little and failed to respond to steroids or a trial of bowel sterilisation. Possibly the cerebral circulation was obstructed by erythrocyte aggregates during the severe haemolysis, but exudates and other retinal changes that would have suggested multiple microinfarction were never seen, and there was no necropsy evidence to support this explanation.The association of haemolysis, active cirrhosis, and a positive antinuclear factor titre in this patient sugge...