Three cases of drug-induced liver injury – what is the diagnosis and management?
| Case 1 |
| A 33-year-old male was admitted with a 2-week history of jaundice. He had been prescribed a 5-day course of flucloxacillin 3 weeks previously for an ingrown toenail. |
| Investigations demonstrated bilirubin 120 μmol/L (peak 614 μmol/L), AST 244 iu/L, ALT 312 iu/L, ALP 130 iu/L, γGT 72 iu/L and INR 1.0. Liver screen, including viral serology and imaging, were unremarkable. |
| Case 2 |
| A 62-year-old female was referred for abnormal liver tests: ALT 125 iu/L, ALP 245 iu/L. On examination, she had stigmata of chronic liver disease, and further investigation revealed a positive anti-smooth muscle antibody and elevated immunoglobulins, specifically IgG. Imaging confirmed cirrhosis. She had commenced a statin 1 year previously. |
| Case 3 |
| A 55-year-old male, co-infected with the hepatitis B (inactive carrier) and hepatitis C virus, was 4 months into a 6-month course of pegylated interferon alpha and ribavirin. He was non-cirrhotic and thus far had shown an excellent response to antivirals with a normal liver panel and negative hepatitis B and C PCR. He was subsequently prescribed a 7-day course of clarithromycin for a chest infection and presented a week later with jaundice and confusion. |
| Investigations demonstrated bilirubin 350 μmol/L, ALT 2000 iu/L and INR 3.0. Liver screen, including viral PCR and imaging, were unremarkable. |
| ALP = alkaline phosphatase; ALT = alanine aminotransferase; AST = aspartate aminotransferase; INR = international normalised ratio; PCR = polymerase chain reaction; γGT = gamma-glutamyl transferase |