Cefprozil as a Cause of Drug-Induced Liver Injury Leading to Acute-on-Chronic Liver Failure

Background: Cases of drug induced liver injury still perplex gastroenterologists due to its wide range of presentations that mimic acute and chronic liver conditions. Moreover, matters get complicated when clinicians face the possibility of drug-induced injury in the presence of pre-existing chronic liver disease. Case: A 69 year-old male who was recently discovered to have a hepatitis C viral infection presented with acute manifestations (mixed cholangio-hepatocellular injury) not fully explained by the underlying chronic disease, we suspected an idiosyncratic reaction from an esterified anabolic androgen. His manifestations have appeared acutely after the drug intake and include acute onset of jaundice, abdominal pain, pruritus and choluria. He was improving on drug discontinuity and conservative measures during his brief hospital stay. Conclusion: The underlying chronic disease constitutes a dilemma in diagnosis of superimposed drug-induced liver injury, as the proof of causality is a daunting task. In such cases, it is tempting to link such new emerging manifestations to be a flare-up of the underlying chronic disease rather than to the drug. However, certain clues helped to point this clinical presentation towards a drug-induced liver injury

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Liver failure

Oxford Textbook of Medicine ◽

10.1093/med/9780198746690.003.0321 ◽

2020 ◽

pp. 3089-3100

Author(s):

Jane Macnaughtan ◽

Rajiv Jalan

Keyword(s):

Liver Transplantation ◽

Liver Disease ◽

Hepatic Encephalopathy ◽

Liver Injury ◽

Liver Failure ◽

Acute Liver Failure ◽

Organ Failure ◽

Clinical Manifestations ◽

Chronic Liver ◽

Chronic Liver Failure

Liver failure occurs when loss of hepatic parenchymal function exceeds the capacity of hepatocytes to regenerate or repair liver injury. Acute liver failure is characterized by jaundice and prolongation of the prothrombin time in the context of recent acute liver injury, with hepatic encephalopathy occurring within 8 weeks of the first onset of liver disease. Acute-on-chronic liver failure is characterized by hepatic and/or extrahepatic organ failure in patients with cirrhosis associated with an identified or unidentified precipitating event. The commonest causes of acute liver failure are acute viral hepatitis and drugs. Acute-on-chronic liver failure is most commonly precipitated by infection, alcohol abuse, and superimposed viral infection. The main clinical manifestations are hepatic encephalopathy, coagulopathy, jaundice, renal dysfunction, and haemodynamic instability. Infection and systemic inflammation contribute to pathogenesis and critically contribute to prognosis. Specific therapy for the underlying liver disease is administered when available, but this is not possible for most causes of liver failure. Treatment is predominantly supportive, with particular emphasis on (1) correction or removal of precipitating factors; (2) if encephalopathy is present, using phosphate enemata, nonhydrolysed disaccharide laxatives, and/or rifaximin; (3) early detection and prompt treatment of complications such as hypoglycaemia, hypokalaemia, cerebral oedema, infection, and bleeding. The onset of organ failure should prompt discussion with a liver transplantation centre. The mortality of acute liver failure (without liver transplantation) is about 40%. Patients with acute liver failure who do not develop encephalopathy can be expected to recover completely. Those who recover from an episode of acute-on-chronic liver failure should be considered for liver transplantation because otherwise their subsequent mortality remains high.

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Kratom-Induced Cholestatic Liver Injury and Its Conservative Management

Journal of Investigative Medicine High Impact Case Reports ◽

10.1177/2324709619836138 ◽

2019 ◽

Vol 7 ◽

pp. 232470961983613 ◽

Cited By ~ 4

Author(s):

Christopher T. Fernandes ◽

Umair Iqbal ◽

Sean P. Tighe ◽

Aijaz Ahmed

Keyword(s):

Liver Disease ◽

Liver Injury ◽

Chronic Liver Disease ◽

The United States ◽

Chronic Liver ◽

Herbal Supplement ◽

Herbal Supplements ◽

Drug Induced ◽

Drug Induced Liver Injury ◽

Analgesic Effects

Drug-induced liver injury (DILI) is a common cause of hepatotoxicity associated with prescription-based and over-the-counter exposure to medications and herbal supplements. Use of unapproved and inadequately tested herbal supplements can cause DILI. Therefore, thorough history-taking on exposure to herbal supplements must be an integral part of clinical evaluation of DILI. Kratom is an herbal supplement or remedy that has been known for its analgesic effects and has also been used for self-treatment of opiate withdrawals. A 52-year-old man was seen for evaluation of yellow discoloration of the eyes and skin. He reported taking kratom for right shoulder strain for at least a couple of months. On workup, his total bilirubin was noted to be 23.2 mg/dL, which peaked at 28.9 mg/dL. He was noted to have mild elevation of aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase. Extensive laboratory tests were ordered and known causes of chronic liver disease ruled out. Magnetic resonance imaging of the abdomen was unremarkable without stigmata of portal hypertension or signs of chronic liver disease. He demonstrated no evidence of coagulopathy or hepatic encephalopathy during his illness. He underwent liver biopsy, which demonstrated histologic evidence of acute cholestatic hepatitis highly suspicious of DILI. He was advised to avoid kratom or other herbal supplements in future and prescribed ursodeoxycholic acid with significant improvement in his liver chemistries. Kratom is associated with significant liver enzymes derangements leading to DILI. Kratom is not approved for use in the United States and should be avoided.

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A Patient with Nafcillin-Associated Drug-Induced Liver Failure

Case Reports in Gastroenterology ◽

10.1159/000480071 ◽

2017 ◽

Vol 11 (3) ◽

pp. 564-568 ◽

Cited By ~ 1

Author(s):

Qin Rao ◽

Isaiah Schuster ◽

Talal Seoud ◽

Kevin Zarrabi ◽

Nirvani Goolsarran

Keyword(s):

Liver Injury ◽

Liver Function ◽

Liver Failure ◽

Acute Liver Injury ◽

Early Recognition ◽

Antibiotic Use ◽

Liver Function Tests ◽

The United States ◽

Drug Induced ◽

Drug Induced Liver Injury

Nafcillin-induced acute liver injury is a rare and potentially fatal complication that has been known since the 1960s but inadequately studied. At this time, the only proven treatment is early discontinuation of the drug. Because of the high prevalence of nafcillin class antibiotic use in the United States, it is important for clinicians to have a high clinical suspicion for this diagnosis. We present a case of liver failure attributable to nafcillin use in a 68-year-old male with a history methicillin-sensitive Staphylococcus and L3/L4 osteomyelitis. After starting long-term antibiotic therapy, he presented with painless jaundice which necessitated discontinuation of the drug. At the time of presentation, the patient’s lab work exhibited a bilirubin/direct bilirubin of 9.4/8.2 mg/dL, alkaline phosphatase of 311 IU/L, and aspartate transaminase/alanine transaminase of 109/127 IU/L. The patient was switched to i.v. vancomycin given the concern for drug-induced liver injury. Imaging did not show obstruction of the hepatobiliary or pancreaticobiliary trees. Serology was unremarkable for viral etiology, autoimmune processes, Wilson disease, and hemochromatosis. A liver biopsy showed findings consistent with drug-induced liver injury. The patient’s liver function tests peaked at day 7 of admission and trended towards normal levels with cessation of nafcillin therapy. The patient was discharged with a diagnosis of nafcillin-induced acute liver injury. Our case highlights the importance of early recognition of the diagnosis and careful monitoring of liver function when nafcillin is employed in the clinical setting.

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