VA Caribbean Health Care System Toa Alta, Puerto Rico
Introduction: Drug-induced liver injury (DILI) is defined as a liver injury caused by various medications, leading to abnormalities in liver tests or liver dysfunction. Amoxicillin–clavulanate (AC) is the most frequent cause of idiosyncratic DILI, and the clavulanic acid component is the likely injurious agent. Pre-existing liver disease is associated with higher rates of severe DILI and three times higher risk of mortality in comparison to those without prior liver disease.
Case Description/Methods: 73-year-old male with a history of chronic liver disease secondary to hemochromatosis and alcohol abuse presented with progressive jaundice, pruritus and choluria for a week. He received a 14-day course of Amoxicillin-Clavulanate for right gluteal abscess 2 weeks prior to presentation. Physical examination pertinent for jaundice and stigmata of chronic liver disease. Laboratories displayed a disproportionate elevation in alkaline phosphatase (417 U/L) compared to serum aminotransferases (AST 112U/L, ALT 92 U/L). Bilirubin levels were significantly elevated at 18.1 mg/dl with direct predominance >10.0mg/dl; all labs consistent with cholestatic injury. Serologies revealed a negative HAV IgM, HBSAg, HB core IgM, and HCV PCR. MRCP showed no evidence of choledocholithiasis or intra or extrahepatic biliary ductal dilatation. No evidence of an active infection. The patient was managed with rifaximin, lactulose, spironolactone, furosemide, and cholestyramine powder. Clinical scenario was then complicated by acute disseminated intravascular coagulation (DIC) and multiorgan failure. Despite aggressive management with blood products, antibiotics, vasopressors, rewarming, fluids, colloid administration, and critical care therapy, the patient did not survive admission. Pathology autopsy report with macronodular cirrhosis, ductular reaction, macrovesicular steatosis, stasis, hemorrhage, and iron depositions with determination of cirrhosis and hepatic failure as primary cause of death.
Discussion: This case report emphasizes the importance of identifying potential hepatotoxic agents such as AC in patients with already established chronic liver disease as they can precipitate life threatening complications such as DILI or DIC. Physicians should also be aware that susceptibility to drugs or chemical compounds can be altered in iron-overloaded livers such as this patient with known history of Hemochromatosis.
