B0615 - Hereditary Hemochromatosis Unmasked by Drug-Induced Liver Injury From Amoxicillin-Clavulanate

Stefan Canacevic, MD¹, Anjali Raj, MD¹, Brandee Albert, DO^2
1Hamilton Medical Center, Chattanooga, TN; ²Hamilton Medical Center, Dalton, GA

Introduction: Drug-induced liver injury from amoxicillin-clavulanate remains one of the most frequent causes of non-acetaminophen drug-induced liver injury per prospective registries across the US and Europe. It is estimated the incidence is 14-19 cases per 100,000. Patients typically present with symptoms of cholestasis – fatigue, nausea, loss of appetite and pruritis. This translates to cholestatic liver enzyme abnormalities. It is important to rule out other causes of liver injury which makes DILI a difficult diagnosis. We present a patient with newly diagnosed hereditary hemochromatosis unmasked by drug induced liver injury secondary to amoxicillin-clavulanate use.

Case Description/Methods: 75-year-old female presented to her primary care provider for sinusitis and was prescribed amoxicillin-clavulanate two weeks prior. She began to experience nausea, vomiting, reflux and epigastric abdominal pain. She subsequently developed worsening pruritus, and scleral icterus. No other new medications or alcohol use were reported. Lab work showed an alkaline phosphatase of 574, AST 251, ALT 602, total bilirubin 4.2 and INR of 1.06. Elevated ferritin of 635 and iron saturation of 94%. Abdominal ultrasound and CT abdomen/pelvis were unremarkable. Trending of lab work showed ALP peak value of 682 and total bilirubin of 5.0 while AST and ALT were down-trending. Extended liver work up revealed a negative acute hepatitis panel, ANA positivity however anti-actin antibody, anti-smooth muscle antibody, and anti-mitochondrial antibody were all negative. Interestingly, the patient was found to be an HFE H63D homozygote. Gastroenterology follow up was arranged one week after hospital discharge with lab work at that time showing improving values ALP 571, AST 144, ALT 233, and total bilirubin of 2.7. Patient required cholestyramine, ursodiol and hydroxyzine to control the pruritus, otherwise the remainder of her symptoms were vastly improved. She was referred to Hematology-Oncology for further evaluation of Hemochromatosis.

Discussion: The exact mechanism of amoxicillin-clavulanate causing drug induced liver injury is unknown, but theorized to be in relation to an immune-allergic response. The onset of injury can last up to 8-10 weeks, fortunately there is rarely long-lasting injury. Similar to our patient, there has been a prior report of a patient with acute liver injury with jaundice secondary to amoxicillin-clavulanate which obscured underlying hemochromatosis diagnosed during the work up.


Disclosures:


Stefan Canacevic, MD¹, Anjali Raj, MD¹, Brandee Albert, DO². B0615 - Hereditary Hemochromatosis Unmasked by Drug-Induced Liver Injury From Amoxicillin-Clavulanate, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.