Camphor Hepatotoxicity

Aliye Uc, MD, Warren P. Bishop, MD, and Kathleen D. Sanders, MD, Department of Pediatrics, University of Iowa College of Medicine, Iowa City, Iowa

South Med J. 2000;93(6) 

In This Article

Case Report

A 2-month-old baby girl was brought to a local hospital because of a recent swelling in the right inguinal area. On physical examination, she looked malnourished with loss of subcutaneous tissue. Her weight was 2,700 g, length was 54 cm, and head circumference 36 cm (all below the fifth percentile). The abdomen was soft, and a soft liver edge was palpated 1.5 cm below the right costal margin. A small, right inguinal hernia was palpated and easily reduced. Failure to thrive was presumed to be related to an improperly diluted formula (15 kcal/oz instead of 20 kcal/oz), and the infant was admitted for nutritional rehabilitation. On admission, she weighed less than her birth weight.

Complete blood count, capillary blood gas values, serum glucose level, electrolyte values, thyroid and kidney function test results, sweat chloride value, and findings on chest x-ray film and urinalysis were all normal. Other values were total protein 6.1 g/dL, albumin 4.1 g/dL, aspartate aminotransferase (AST) 54 U/L, total bilirubin 0.3 mg/dL, and lactate dehydrogenase (LDH) 254 U/L. The baby was fed with a soy protein-based formula (20 kcal/oz) with a caloric intake of 150 to 165 kcal/kg/day, and she averaged a weight gain of 50 g per day.

On the third hospital day, serum calcium, phosphorus, potassium, magnesium, and liver function values were checked to monitor for refeeding syndrome. Refeeding syndrome can occur in severely malnourished patients receiving nutritional rehabilitation, mostly through a parenteral route.[7] It is characterized by hypophosphatemia, hypocalcemia, hypokalemia, and hypomagnesemia. If unrecognized, refeeding syndrome can cause significant morbidity and mortality. In our case, the refeeding syndrome was ruled out by normal calcium, phosphorus, potassium, and magnesium levels in the serum. Results of liver function tests were elevated and continued to rise (Table 1). Prothrombin time and partial thromboplastin time were normal. Toxoplasma, cytomegalovirus, herpesvirus, Epstein-Barr virus antibody titers were negative, the serum alpha 1-antitrypsin level was normal, and serologic studies were negative for hepatitis A, B, and C viruses. On the fifth day of hospitalization, the baby was transferred to the University of Iowa Hospitals and Clinics for further evaluation of elevated liver function values.

At admission, the patient appeared malnourished but alert and in no acute distress. A soft liver edge was palpated 1.5 cm below the right costal margin. Abdominal ultrasonography showed a normal liver. Serum calcium, phosphorus, magnesium, and electrolyte values were normal. Serial liver function tests were done (Table 1). The mother was questioned thoroughly for a possible medication use before the hospitalization. She remembered applying generous amounts of a cold remedy (Vicks VapoRub) to the baby's chest and neck, three times a day for 5 days and had stopped applying it just before the child was transferred to the University Hospital. The infant's liver function normalized rapidly without intervention, and she was discharged home with proper instructions about how to mix the formula. The mother was also instructed not to apply the cold medicine again, at least not until after age 2. Three months after discharge, the baby was gaining weight well, and findings on liver function tests were completely normal.

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