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Metamizole Use by Latino Immigrants: a Common and Potentially Harmful Home Remedy

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Metamizole Use by Latino Immigrants: a Common and Potentially Harmful Home Remedy Metamizole Use by Latino Immigrants: A Common and Potentially Harmful Home Remedy Joshua L. Bonkowsky, MD, PhD*; J. Kimble Frazer, MD, PhD*; Karen F. Buchi, MD*‡; and Carrie L. Byington, MD*‡§ ABSTRACT. A 4-year-old boy presented with fever, States to travelers regarding the risks of medications septic arthritis, and persistent neutropenia. Bone marrow that contain pyrazolone analgesics,2 many US physi- biopsy revealed no evidence of neoplasia. Additional cians remain unaware of these potentially harmful history disclosed that the patient had been given met- medications. amizole for pain before onset of his illness. Metamizole, a nonsteroidal antiinflammatory agent, is prohibited in the United States because of the risk of agranulocytosis CASE REPORTS but is widely used in Mexico and other countries. The A 4-year-old Latino boy presented to an urban public health increasing number of Latinos in the United States and clinic in Salt Lake City, Utah, for evaluation of limp and fever. His the extensive cross-border transfer of medicines raise parents had given him Neo-melubrina (metamizole) for his symp- concerns that metamizole use and associated complica- toms. His medical history was unremarkable. The boy’s family tions may become more frequent. After identification of history was remarkable for sepsis in the mother 5 months before the index patient, additional inquiry revealed that the the child’s illness. His social history was notable for recent emi- gration from Mexico. patient’s mother was hospitalized previously for over- Physical examination revealed a temperature of 39.5°C and whelming sepsis associated with metamizole use. These active resistance to rotation of his left hip. Laboratory testing cases prompted an investigation of metamizole use in an demonstrated a white blood cell count (WBC) of 3800/␮L (19% urban pediatric clinic, which revealed that 35% of Span- band forms, 26% segmented neutrophils, 48% lymphocytes, 7% ish-speaking Latino families had used metamizole; 25% monocytes), absolute neutrophil count (ANC) of 1710, hemoglobin of these families had purchased the medication in the 12.3 g/dL, platelets 285 000/␮L, Westergren erythrocyte sedimen- United States. We conclude that metamizole use is com- tation rate of 20 mm/h, and C-reactive protein of 1.7 mg/dL. mon and may be underrecognized in immigrant Latino Radiographs of the hips showed an effusion on the left, subse- patients. Physicians in the United States, especially those quently confirmed by ultrasonography. A bone scan was normal. Hip joint aspiration yielded cloudy fluid; Gram stain was nega- who practice primary care, hematology/oncology, and in- tive. A bacterial culture of synovial fluid was obtained. The patient fectious diseases, must be aware of the availability and was admitted, and treatment with nafcillin and clindamycin was use of metamizole in specific patient populations and its initiated. potential for harmful side effects. Pediatrics 2002;109(6). The patient remained febrile to 40.4°C, and the C-reactive pro- URL: http://www.pediatrics.org/cgi/content/full/109/6/ tein increased to 4 mg/dL. The WBC decreased to 2800/␮L with e98; metamizole, neutropenia, home remedy. an ANC of 1190. Hematopathologic evaluation of the peripheral blood smear revealed neutropenia, lymphopenia, and a single myeloid blast. The synovial fluid culture yielded Enterobacter ag- ABBREVIATIONS. WBC, white blood cell; ANC, absolute neutro- glomerans. Antibiotic coverage was adjusted. Left hip arthrotomy phil count; G-CSF, granulocyte-colony stimulating factor. and bone marrow biopsy were performed 2 days after admission. The bone marrow demonstrated normocellular marrow and no evidence of myelodysplasia but revealed myeloblastosis consis- etamizole, or dipyrone, is a pyrazolone tent with a reactive process. The patient’s ANC decreased to 640. nonsteroidal antiinflammatory agent.1 It The patient received 2 doses of granulocyte colony-stimulating has been associated with fatal agranulocy- factor (G-CSF) with temporary improvement. A repeat bone mar- M row biopsy was performed 22 days after admission secondary to tosis and was withdrawn from the US market by the a persistently low ANC; no evidence of a neoproliferative process US Food and Drug Administration in 1979.1 Met- was seen. The patient completed a 28-day course of antibiotics. amizole is available without a prescription in Mexico One month postdischarge, his WBC was 5500/␮L with an ANC of and other countries and is used to treat fever and 3410. The patient’s 27-year-old mother was interviewed, and her pain. It is marketed in Latin America under hun- medical records were reviewed. She reported 1 week of fever and dreds of brand names, including Neo-melubrina (Ta- abdominal pain 5 months before her child’s presentation for which ble 1). Despite the common use of metamizole in she purchased Neo-melubrina and an antibiotic to treat her symp- other countries and warnings issued in the United toms. Her symptoms worsened, and she was admitted to the hospital with a temperature of 40°C, disseminated intravascular coagulation, and shock. Computed tomography of the abdomen revealed acute cholecystitis. She required treatment in the inten- From the *Department of Pediatrics, ‡Division of General Pediatrics, §Di- sive care unit, and she completed a 10-day course of antibiotics. vision of Infectious Diseases and Geographic Medicine, University of Utah, During her hospitalization, her WBC counts ranged from 3000 to Salt Lake City, Utah. 4000/␮L with an ANC of 1500 to 2000 and an absolute lymphocyte Received for publication Dec 28, 2001; accepted Feb 14, 2002. count of 700. Reprint requests to (C.L.B.) Division of Infectious Diseases and Geographic The family purchased Neo-melubrina without a prescription Medicine, Department of Pediatrics, University of Utah, 50 North Medical from a Latin American market in Salt Lake City. No directions or Dr, Salt Lake City, UT 84132. E-mail: [email protected] warnings were included with the medication. Members of the PEDIATRICS (ISSN 0031 4005). Copyright © 2002 by the American Acad- clinic staff were able to purchase the same medication at the emy of Pediatrics. market. http://www.pediatrics.org/cgi/content/full/109/6/Downloaded from www.aappublications.org/newse98 by guestPEDIATRICS on September Vol.28, 2021 109 No. 6 June 2002 1of3 TABLE 1. Common Preparations That Contain Metamizole Manufactured in Mexico1,25 Generic Description Brand Name (Mexican Manufacturer) Marketed Indication Metamizole or dipyrone Conmel (Sanofi Winthrop) Pain or fever as a single agent Dalmasin (Columbia) Fardolipin (Farcoral) Magnol (Atlantis) Neo-melubrina (Hoechst Marion Roussel) Prodolina (Promeco) Utidol (Diba) Metamizole or dipyrone Bipasmin Compuesto (Promeco) Relief of smooth muscle plus pargeverine pain and spasm hydrochloride Metamizole or dipyrone Buscapina Compositum Relief of smooth muscle plus hyoscine (Boehringer Ingelheim Sons) pain and spasm butylbromide Busconet (Sons) Busprina (Farcoral) Colepren (Randall) Retodol Compositum (Rimsa) Metamizole or dipyrone Dolnefort (Farcoral) Pain and neuritis plus vitamin B Dolo-Tiaminol (Silanes) SURVEY aware of potentially harmful folk or home remedies Approval was obtained from the University of used by different cultural groups. The medical liter- Utah Institutional Review Board. During the first 2 ature has several examples of serious illness and weeks of October 2001, all Spanish- or Portuguese- even death caused by home remedies.3–5 The pa- speaking parents of children who were evaluated in tients in this report had neutropenia or leukopenia the clinic were asked 5 questions regarding met- and serious infection associated with metamizole amizole by the child’s pediatrician, either a resident use. Neutropenia can be the result of serious infec- or a faculty physician. Questions included whether tion but would be expected to be short-lived, espe- the adult had ever used Neo-melubrina, metamizole, cially after the initiation of antibiotic therapy.6,7 The dipyrone, or dipirona; whether the adult had ever patients in this report both had abnormalities of neu- given this medication to a child; whether the family trophils for weeks even on appropriate antibiotic had the medication in their home; whether they had therapy and the pediatric patient required G-CSF purchased the medication in the United States; and therapy, consistent with other reports of neutropenia their country of origin. A standard form was at- associated with metamizole use.8 Because met- tached to their charts, and the clinic physicians were amizole has been banned in the United States for instructed to ask the parents the survey questions more than 2 decades, most practicing physicians may while obtaining the patient’s history. Questions were be unfamiliar with the medication and its side ef- asked in the patient’s preferred language, and fects. trained medical interpreters were available for phy- Agranulocytosis and aplastic anemia are the lead- sicians who were unable to speak Spanish. The chil- ing causes of drug-induced death.9 An international dren of surveyed parents ranged in age from 3 days study performed in the 1980s associated metamizole to 14 years. All parents approached answered all of with agranulocytosis, although risk varied by coun- the survey questions. After the survey, parents were try.10 A population-based study in the Netherlands educated regarding the dangers of metamizole and described a 23-fold increased relative risk of agran- given recommendations
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