P0781 - The Mischievous Pills

Reyshley Ramos-Marquez, MD, Hendrick Pagan-Torres, MD, Loscar Santiago-Rivera, MD, FACG
VA Caribbean Healthcare System, San Juan, Puerto Rico

Introduction: Diagnosis of drug induced autoimmune-like hepatitis (DIAIH) can be challenging. The majority of cases are associated to minocycline and nitrofurantoin and less than five cases related to Cephalexin have been described in literature. It is important to be aware of risk factors and pharmacological agents associated to this condition to provide an adequate management, since these patients do not seem to require long-term immunosuppressive therapy compared to patient with classic Autoimmune Hepatitis. We report a case of a patient with DIAIH due to Cephalexin who demonstrated marked improvement after cessation of this antibiotic not requiring steroid therapy.

Case Description/Methods: A 73-year-old male with medical history of Metabolic Syndrome, Uncontrolled Diabetes Mellitus Type 2, and Coronary Artery Disease presented with three days of jaundice and right upper quadrant abdominal pain. Denied use of herbal or natural supplements, however referred recent completion of therapy with Cephalexin for a complicated urinary tract infection. Physical exam was remarkable for icteric sclera, jaundiced skin, and abdominal tenderness. Laboratories showed AST and ALT at 879 U/L and 212 U/L, respectively, with an ALP of 1155 U/L and a total bilirubin of 9.32 mg/dl with prolonged INR. An MRCP/MRI was unremarkable. PET CT was done and resulted negative for lesions. Serology work up was only remarkable for positive ANA of 1:320 and elevated IgG at 1928 mg/dL. Liver biopsy noteworthy for foci of portal tract expansion by a mononuclear inflammatory infiltrate with scattered plasma cells and focal bile duct damage suggestive of interphase hepatitis. Transplant Center evaluated case and steroid therapy was recommended due to findings consistent with DIAIH. Due to side effects of steroids and patients’ comorbidities, family decided not to undergo treatment with steroids. Follow up at GI clinics at 3 months, AST and ALT levels were 68 U/L and 21 U/L, respectively, with an ALP of 243 U/L, a total bilirubin of 1.99 mg/dL and symptoms resolved.

Discussion: DIAIH has been reported to be caused by different drugs, and Cephalexin is an uncommon cause of this disease. Management of DIAIH consists on discontinuation of offending drug and steroids therapy which usually can be discontinued without relapse. This case demonstrates that discontinuation of the offending drug is the essential treatment and luckily for our patient spontaneous improvement occurred.


Disclosures:


Reyshley Ramos-Marquez, MD, Hendrick Pagan-Torres, MD, Loscar Santiago-Rivera, MD, FACG. P0781 - The Mischievous Pills, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.