A case of severe terbinafine induced gastritis presenting as a likely protein losing enteropathy
This paper reports a rare case of severe terbinafine-induced gastritis presenting as protein-losing enteropathy in a patient with POEMS syndrome, which resolved upon discontinuation of the drug and highlights the need to consider medication-induced gastritis when common causes are excluded.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Imagine your stomach lining as a bustling, well-fortified castle wall. Usually, when this wall gets irritated, it's because of a tiny, sneaky invader named Helicobacter pylori or because someone kept poking it with chemical weapons like painkillers. But in this strange medical mystery, the culprit wasn't a bug or a common painkiller. It was a nail fungus medication called terbinafine.
Here's the story of a 58-year-old man whose castle wall didn't just get a scratch; it got turned into a sieve.
The Mystery of the Leaky Castle
Two months before he got sick, this man started taking oral terbinafine to fix his toenail fungus. He had a history of a complex condition called POEMS syndrome, but that was under control thanks to a bone marrow transplant. So, he thought he was in the clear.
Then, the trouble started. For three weeks, he suffered from watery diarrhea, nausea, tummy aches, and his body began to swell up like a balloon. The swelling was so severe that his pitting edema (that's when you press your skin and it leaves a dent) reached all the way up to his chest!
When doctors checked his blood, they found something alarming: his serum albumin was dangerously low at 18 g/L. Think of albumin as the "glue" that holds water inside your blood vessels. When the glue disappears, the water leaks out into your tissues, causing that massive swelling. His globulin was also low at 16 g/L.
The Detective Work
The doctors had to play detective to figure out why his body was leaking protein.
- Was it an infection? They checked for H. pylori, but the castle was clean. No bugs found.
- Was it the kidneys? They checked his urine, and it was normal. No protein was leaking out there.
- Was it the intestines? They looked at his colon with a camera, and aside from a tiny, harmless polyp, everything looked fine.
- Was it the stomach? This is where the plot thickened. When they looked inside his stomach, they saw severe diffuse nodular gastritis (a very angry, bumpy inflammation) with a weird twist: the bottom part of the stomach (the antrum) was spared, like a fortress that was attacked everywhere except the gatehouse.
The tissue samples showed the wall was eroding and trying to heal itself frantically, a sign of chemical gastropathy. This means the damage was caused by a chemical irritant, not a bacteria.
The "Leaky Gut" Theory
The doctors suspected the man was suffering from Protein-Losing Enteropathy (PLE). Imagine your digestive tract as a pipe that's supposed to keep protein inside. In PLE, the pipe develops holes, and the protein leaks out into the gut and gets pooped out instead of staying in the blood.
The paper suggests this was the case because his protein levels crashed, he had no other signs of inflammation (his C-reactive protein was normal), and he wasn't losing protein through his kidneys. However, there was a hiccup: the test that would have confirmed this (measuring faecal alpha-1-antitrypsin) failed because the sample was mishandled. So, while the evidence points strongly to a leaky gut, the paper says it's a "likely" diagnosis rather than a 100% confirmed one.
The Solution: Pull the Plug
The most exciting part of the story is how it ended. The doctors didn't need a magic potion or a new surgery. They simply told the patient to stop taking the terbinafine.
It worked like a charm. His symptoms vanished on their own. Three months later, when they looked inside his stomach again, the angry, bumpy wall had healed completely. His albumin levels bounced back to a healthy 42 g/L.
What Does This Tell Us?
This case is a bit of a medical oddity. While terbinafine is known to sometimes cause mild tummy trouble, it is not known to cause severe damage like this. In fact, one study mentioned in the paper found severe side effects in only 0.04% of patients.
The authors suggest that terbinafine might be causing this severe inflammation through a mechanism similar to how it sometimes hurts the liver—perhaps by triggering a flood of inflammatory signals. But they are careful to say this is a possibility, not a proven fact.
The Takeaway:
If you have severe stomach issues, diarrhea, and swelling, and the usual suspects (like H. pylori) are ruled out, doctors should consider that a medication like terbinafine might be the villain. If you are taking it for a long time and feel sick, the paper suggests that adding acid-suppressing medicine might be a good idea, just to be safe.
This story proves that even common medicines can have rare, dramatic side effects, and sometimes the best cure is simply stopping the drug that started the trouble.
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