E0600 - An Unusual Case of Drug-Induced Liver Injury Secondary to Nitrofurantoin Use

Vikash Kumar, MD¹, Stephen Wonnacott, MS², Dhir Gala, BS², Anmol Mohan, MBBS³, Mili Shah, BS², Jasparit Minhas, MD^1
1The Brooklyn Hospital Center, Brooklyn, NY; ²American University of the Caribbean School of Medicine, Brooklyn, NY; ³Karachi Medical & Dental College, Karachi, Sindh, Pakistan

Introduction: Nitrofurantoin is a commonly prescribed antibiotic for uncomplicated urinary tract infections (UTI). One of nitrofurantoin's rare, however significant, adverse effects is idiosyncratic drug-induced liver injury (DILI).

Case Description/Methods: A 24-year-old obese female with a past medical history of GERD presented to the emergency department complaining of epigastric pain with nausea and vomiting for the past few hours. The patient was recently diagnosed with a UTI and took nitrofurantoin (50 mg every 6 hours) for the past 3 days. Blood tests on admission were significant for direct bilirubin of 0.7 mg/dL, total bilirubin of 1.9 mg/dL, AST of >717 U/L, and ALT of 476 U/L. The patient had liver function tests (LFTs) a week ago, which were normal. Toxicology labs were negative for acetylsalicylic acid, acetaminophen, and alcohol. Viral workups, including Hepatitis tests, were negative for hepatitis A, B, C, and E and showed immunity for hepatitis A with IgG positive/IgM negative. Autoimmune workup including antinuclear antibodies (ANA), Anti-smooth muscle, anti-mitochondrial, and anti-LK- antibodies were negative. Ultrasound showed stones within the gallbladder. Nitrofurantoin was immediately discontinued, and after 3 days in the hospital, symptoms subsided. Repeat LFTs showed enzyme values trending towards normal (Table 1). The patient was educated to follow up with PCP for repeat LFTs and chances of possible relapse with similar medications on discharge.

Discussion: DILI can be a rare and fatal adverse effect of nitrofurantoin use. There is a higher risk of developing DILI from taking nitrofurantoin for female patients with increased age, reduced renal function, or increased duration of treatment with the drug. DILI generally presents in two forms with nitrofurantoin, acute and chronic. Acute DILI can present with fever, rash, eosinophilia, hepatomegaly, jaundice, abdominal pain, nausea, malaise, pulmonary signs, anorexia, and elevated liver enzymes. Most cases of acute DILI due to nitrofurantoin will resolve on their own after discontinuation of the drug but should be monitored in case chronic liver injury develops. Severe cases may require treatment with steroids, N-acetylcysteine, or transplantation. Our patient presented with signs of liver damage after starting a course of nitrofurantoin for a lower urinary tract infection. Once treatment was discontinued, the patient’s condition improved, consistent with DILI.



Disclosures:


Vikash Kumar, MD¹, Stephen Wonnacott, MS², Dhir Gala, BS², Anmol Mohan, MBBS³, Mili Shah, BS², Jasparit Minhas, MD¹. E0600 - An Unusual Case of Drug-Induced Liver Injury Secondary to Nitrofurantoin Use, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.