Scleral icterus

The sinusoids transport both portal and arterial blood to the hepatocytes. The systemic blood delivered to the liver contains nutrients, drugs, and ingested toxins. The liver processes the nutrients (carbohydrates, proteins, lipids, vitamins, and minerals) for either immediate use or for storage, while the drugs and toxins are metabolized through a variety of processes known as first-pass metabolism. The liver also processes metabolic waste products for excretion. In cirrhosis, bilirubin (from the enzymatic breakdown of heme) can accumulate this causes jaundice (yellowing of the skin), scleral icterus (yellowing of the sclera), and tea-colored urine (urinary bilirubin excretion). 

Jaundice may be evident in the whites of the eyes (scleral icterus) or skin. 

HEENT Scleral icterus, dry mucous membranes, pinpoint pupils, dilated and fixed pupils, nystagmus... 

Usual clinical signs and symptoms of SCD are chronic anemia fever pallor arthralgia scleral icterus abdominal pain weakness anorexia fatigue enlarged liver, spleen, and heart and hematuria. 

Adverse reactions occurring in at least 3% of patients include the following abdominal pain, diarrhea, dizziness, headache, insomnia, jaundice/scleral icterus, myalgia, nausea, peripheral neurologic symptoms, rash, vomiting. 

The adverse effects of atazanavir include fever, jaundice/scleral icterus, myalgia and diarrhea. Its coadministration is not recommended with the drugs that induce cytochrome P-450 isoenzyme CYP3A4. Ritonavir increases plasma concentrations of atazanavir. It is an inhibitor of isoenzymes CYP3A4, CYP2C8 and UGT1A1. The coadministration of atazanavir with calcium channel blockers, HMG-CoA reductase inhibitors, immunosuppressants and phosphodiesterase 5 inhibitors should be carefully monitored. 

A 49-year-old man developed scleral icterus with raised bilirubin and transaminases after using pioglitazone 15-30 mg for 6 months and 45 mg for 1 week (105). No other cause for hepatitis was found. After withdrawal his liver function improved substantially within 14 days. 

Head, ears, eyes, nose, and throat (HEENT) -discoloration of conjunctivae (red, orange, brown, or brassy reportedly distinct from hyperbilirubinemia), scleral icterus, garlic odor to breath (possible). 

Scleral icterus occurs from a serum bilirubin level of 1.6-1.8 mg/dl upwards. At the same time, the conjunctiva is icterially discoloured. Jaundice is based on the affinity of the elastic fibres for bilirubin. 

The term jaundice or icterus is used to depict the yellowish discolouring of the skin, mucous membranes and body fluids witnessed as a result of hyperbilirubinaemia in excess of 2.5 mg/dl, with subsequent deposition of bile pigments in tissue which is rich in elastin. In cases of severely impaired liver function or renal insufficiency, bilirubin values can rise dramatically. The term subicterus is used to describe a low-grade icteric condition occurring in the region of the white sclera with a serum bilirubin value of > 1.8 mg/dl for this reason, it is also known as scleral icterus, (s. pp 80, 99)... 

Jaundice, scleral icterus, bleeding within 3 to 10 days... 

Hepatic dysfunction with scleral icterus and diffuse jaundice was reported in a 42-year-old man who had consumed 1440 mg chaparral daily for 6 weeks. The patient returned to normal 1 month after discontinuing chaparral (Clark and Reed 1992 Sheikh et al. 1997). 

Jaundice with possible toxic liver damage was reported in a 71-year-old man who had been taking an unspecified amount of chaparral capsules daily for an unspecified amount of time. Symptoms of flu-like illness, ascites, and jaundice abated 2 months after cessation of chaparral. The man had a history of alcohol use (14 oz wine daily). One month after restarting chaparral use, the man developed jaundice, ascites, scleral icterus, and nausea. Liver biopsy indicated diffuse necrosis with inflammation, portal tract expansion, mild cholestasis, and mild fibrous septation. A biopsy 3 months later indicated marked improvement (Batchelor et al. 1995). 

---