Schizophrenic Patient with Drug Induced Liver Injury Initially Misdiagnosed as Wilson’s Disease with Final Diagnosis of Celiac Disease

Abstract Background Drug induced liver injury (DILI) is an important cause of acute liver injury and accounts for approximately 10% of all cases of acute hepatitis. Both prescription and natural health products (NHPs) have been implicated in DILI. There is a dearth of studies on NHPs induced liver injury. Case Presentation A previously healthy 37-year-old female presented with subacute hepatitis, in the context of a previous admission to a separate institution, months prior for undiagnosed acute hepatitis. Importantly, she had disclosed taking complex regiments of natural health products (NHPs) for months. Her only other medication was rivaroxaban for her homozygous Factor V Leiden deficiency. She had an extensive work up for causes of acute and unresolving hepatitis. She discontinued several but not all of her NHPs after her initial presentation for acute hepatitis at the first institution and continued taking NHPs until shortly after admission to our institution. The predominant pathological features were that of drug induced liver injury, although an abnormal amount of copper was noted in the core liver biopsies. However, Wilson’s disease was ruled out with normal serum ceruloplasmin and 24-urine copper. After 2 months of stopping all the NHPs, our patient improved significantly since discharge, although there is evidence of fibrosis on ultrasound at last available follow up. Conclusion NHPs are a well-established but poorly understood etiology of DILI. The situation is exacerbated by the unregulated and unpredictable nature of many of the potential hepatotoxic effects of these agents, especially in cases of multiple potential toxic agents. This highlights the importance of acquiring a clear history of all medications regardless of prescription status.

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Clinicopathological Study of Autoimmune Hepatitis Cases That Were Difficult to Differentiate from Drug-Induced Liver Injury

Digestive Diseases ◽

10.1159/000480139 ◽

2017 ◽

Vol 35 (6) ◽

pp. 506-514 ◽

Cited By ~ 6

Author(s):

Akemi Tsutsui ◽

Kenichi Harada ◽

Koichi Tsuneyama ◽

Tomonori Senoh ◽

Takuya Nagano ◽

...

Keyword(s):

Liver Injury ◽

Autoimmune Hepatitis ◽

Scale Score ◽

Plasma Cells ◽

Final Diagnosis ◽

Acute Onset ◽

Pathological Findings ◽

Drug Induced ◽

Drug Induced Liver Injury ◽

Scale Scores

Aim: Acute-onset autoimmune hepatitis (AIH) histopathologically presents with features of acute hepatitis and lacks a specific diagnostic method. Also, AIH is often difficult to differentiate from drug-induced liver injury (DILI). We aimed to investigate the final clinical diagnosis of these cases, and compare the clinical, biochemical, and histological characteristics of AIH vs. DILI. Methods: We examined the Digestive Disease Week Japan 2004 (DDW-J) scale scores, AIH scores, clinical data, and pathological findings in 20 patients in whom it was difficult to differentiate autoimmune liver disease from DILI. Results: In cases with a DDW-J scale score of ≥5, there was a good correlation between the final diagnosis and DDW-J scale assessments, but in cases with a DDW-J scale score of ≦4 they did not correlate well. The scores for pathological findings, such as cobblestone hepatocellular change (p = 0.015), interface hepatitis (p = 0.012), and prominent plasma cells in portal areas (p = 0.011), were higher in the AIH group than in the DILI group. Conclusion: This study showed that DDW-J scale was useful for differentiating AIH from DILI in cases with a DDW-J scale score of ≧5. The histologic features of AIH were characterized by cobblestone hepatocellular change, interface hepatitis, and plasma cell infiltration of the portal region.

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Application of International Consensus Meeting Criteria for Classifying Drug-Induced Liver Disorders

Annals of Pharmacotherapy ◽

10.1177/106002809502900910 ◽

1995 ◽

Vol 29 (9) ◽

pp. 875-878 ◽

Cited By ~ 6

Author(s):

Jean-Francois Bussières ◽

Magdi Habra

Keyword(s):

Liver Injury ◽

Mixed Type ◽

Final Diagnosis ◽

Liver Disorder ◽

Consensus Meeting ◽

Drug Induced ◽

International Consensus ◽

Liver Disorders ◽

Drug Induced Liver Injury ◽

Screening And Diagnosis

Objective: To report a patient with 2 consecutive reversible drug-induced liver disorders and the application of International Consensus Meeting Criteria for the screening and diagnosis of drug-induced liver disorders. Case Summary: An 88-year-old man in a chronic care institution developed abdominal discomfort and jaundice after finishing a 10-day course of trimethoprim/sulfamethoxazole therapy for a urinary tract infection (UTI). The jaundice and the symptoms resolved spontaneously and the final diagnosis was symptomatic drug-induced liver injury, mixed type. After 1 month, the same patient received a course of cefadroxil therapy for another UTI. He developed an asymptomatic drug-induced liver injury, mixed type. Six months later, the patient received oral penicillin therapy and then ciprofloxacin, with no change in his liver function test results. Discussion: To our knowledge, there are only a few other reports in the literature of a drug-induced liver injury with Cefadroxil therapy; more cases are reported with trimethoprim/sulfamethoxazole than with cefadroxil. The criteria of an International Consensus Meeting were helpful to evaluate both incidences of liver injury in this patient with the aim of establishing the diagnosis and causality assessment. Additionally, the criteria were used to show that the patient had 2 separate liver injuries. Conclusions: Screening and diagnosis of drug-induced liver disorders depend on careful history taking and 5 specific biochemical liver tests. The evolution of the liver disorder induced by Cefadroxil therapy probably was interrupted because of its early detection. Appropriate screening was done with the subsequent administration of new potentially hepatotoxic drugs.

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Leberschaden unter oraler Antikoagulation, Statin- und ACE-Hemmertherapie

Praxis ◽

10.1024/1661-8157/a000298 ◽

2010 ◽

Vol 99 (21) ◽

pp. 1259-1265 ◽

Cited By ~ 2

Author(s):

Bruggisser ◽

Terraciano ◽

Rätz Bravo ◽

Haschke

Keyword(s):

Liver Injury ◽

Wird Eine ◽

Drug Induced ◽

Drug Induced Liver Injury

Ein 71-jähriger Patient stellt sich mit Epistaxis und ikterischen Skleren auf der Notfallstation vor. Der Patient steht unter einer Therapie mit Phenprocoumon, Atorvastatin und Perindopril. Anamnestisch besteht ein langjähriger Alkoholabusus. Laborchemisch werden massiv erhöhte Leberwerte (ALAT, Bilirubin) gesehen. Der INR ist unter oraler Antikoagulation und bei akuter Leberinsuffizienz >12. Die weiterführenden Abklärungen schliessen eine Virushepatitis und eine Autoimmunhepatitis aus. Nachdem eine Leberbiopsie durchgeführt werden kann, wird eine medikamentös-toxische Hepatitis, ausgelöst durch die Komedikation von Atorvastatin, Phenprocoumon und Perindopril bei durch Alkohol bereits vorgeschädigter Leber diagnostiziert. Epidemiologie, Pathophysiologie und Klink der medikamentös induzierten Leberschäden (drug induced liver injury, DILI), speziell von Coumarinen, Statinen und ACE-Hemmern werden im Anschluss an den Fallbericht diskutiert.

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