A0567 - Hydralazine-Induced Liver Injury With Autoimmune Features: A Case Report and Literature Review

Sunday, October 23, 2022

5:00 PM – 7:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

RA

Rawan Aljaras, MD

Indiana University School of Medicine
Indianapolis, Indiana

Rawan Aljaras, MD¹, Ahmad Karkash, MD¹, Maryam Haider, MD², Bianca Nicole Puello Yocum, MD¹, Razan Aljaras, MD¹, Gerardo Calderon, MD³
¹Indiana University School of Medicine, Indianapolis, IN; ²Wayne State University/Detroit Medical Center Sinai Grace Hospital, Detroit, MI; ³Indiana University, Indianapolis, IN

Introduction: Autoimmune drug induced liver injury (AI-DILI) is a syndrome characterized by liver injury accompanied by laboratory evidence of autoimmunity due to the ingestion of a drug or herbal product. DILI accounts for approximately 15% of the cases of acute liver failure. Many drugs have been associated with DILI such as Amoxicillin-clavulanate, Diclofenac, Azathioprine, Infliximab. However, very rare cases have been reported on hydralazine-induced DILI. A response to treatment with steroids supports the diagnosis.

Case Description/Methods: We present a case of a 59 year old female with no reported past history of liver disease. Patient was admitted for workup of jaundice, fatigue, and abdominal dissension of one month duration. Labs were significant for liver enzymes elevation with a cholestatic pattern. ERCP and EUS were done and results came back unremarkable. An extensive infectious and autoimmune workup was also negative. On further clarification of medication history, patient appeared to have had started hydralazine roughly 3 months prior to presentation. A liver biopsy was done and showed cholestatic injury and granulomatous inflammation (Figures A&B). Hydralazine was presumed the cause of patient’s liver injury, it was immediately stopped and patient was started on oral prednisone with significant improvement in symptoms and liver function test.

Discussion: Autoimmune features and autoantibody reactivity in such cases of DILI vary according to liver injury severity and disease progression. The presentation of AI-DILI is classically indistinguishable from idiopathic autoimmune hepatitis (I-AIH). The presence of autoimmune features of liver injury due to hydralazine is not associated with the typical HLA alleles found in I-AIH such as HLA-DRB1*03:01 and DRB1*04:01 alleles. Histologically, AI-DILI shows changes that cannot be definitively distinguished from I-AIH without clinical correlation. Features on liver biopsy favoring DILI with autoimmunity include portal inflammation, fibrosis, portal neutrophils and plasma cells, and intracellular cholestasis. Liver biopsy is not performed in many cases of DILI, but may be useful if the liver injury is prolonged and does not promptly resolve with discontinuation of the drug and to also decide on need for treatment with steroids. In the attached table we present a review of the body of research on hydralazine-induced DILI with autoimmune features.

Figure: A- H&E stained section of the liver demonstrates moderate cholestasis (arrows) with surrounding inflammation.
B- H&E stained section of the liver demonstrating a portal triad with mixed inflammation composed of predominately lymphocytes with rare neutrophils and plasma cells and mild interface activity. Moderate bile duct injury is seen (arrow).

Author	Number of cases	Average age	Signs/Symptoms	Sex	Type	Average LFTs	Markers	Course	Outcome
Our case (2022)	1	59	Jaundice, ascites, abdominal distension	F	Cholestatic	ALT 100s AST 200s Bili 17	ANA- ASMA- AMA -	Moderate	Resolved
de Boer (2016)	7	60 (42-76)	Jaundice, itching, rash, fever, eosinophilia	5 F 2 M	Hepatocellular (3) Mixed (2) Cholestatic (2)	ALT 500s AST 1000s ALP 200s Bili 2	-	Mild (2) Moderate (3) Severe (2)	Liver transplant (1) Death (0)
deLemos et al. (2014)	1	42	Flu-like symptoms, jaundice, ascites	M		ALT 1000s AST 1000s ALP 200s INR 2	ANA+ ASMA- AMA-	Very severe	Liver transplant
Donald Rice, MD (1983)	1	51	Nausea, vomiting, malaise, fever, dark urine	F	Granulomatous hepatitis	AST 500s ALP 200s Bili 5	Lupus -	mild	Resolved

Table: Table: Literature review for hydralazine-induced DILI with autoimmune features

Abbreviations: F:female, M:male, LFT: liver function test, ANA:anti-nuclear antibody, ASMA:anti-smooth muscle antibody, AMA:anti-mitochondrial antibody.

Disclosures:

Rawan Aljaras indicated no relevant financial relationships.

Ahmad Karkash indicated no relevant financial relationships.

Maryam Haider indicated no relevant financial relationships.

Bianca Nicole Puello Yocum indicated no relevant financial relationships.

Razan Aljaras indicated no relevant financial relationships.

Gerardo Calderon indicated no relevant financial relationships.

Rawan Aljaras, MD¹, Ahmad Karkash, MD¹, Maryam Haider, MD², Bianca Nicole Puello Yocum, MD¹, Razan Aljaras, MD¹, Gerardo Calderon, MD³. A0567 - Hydralazine-Induced Liver Injury With Autoimmune Features: A Case Report and Literature Review, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.