2306 Hydroxychloroquine-Induced Acute Liver Injury

Abstract

INTRODUCTION: Hydroxychloroquine is a commonly prescribed medication with antimalarial and anti-inflammatory properties. A very rarely reported side effect of this medication is drug induced acute liver injury. CASE DESCRIPTION/METHODS: A 62-year old female with a history of rheumatoid arthritis, on long term prednisone, presented to the emergency department with two day history of arthralgias, generalized weakness, and fever of 104 F. She had no history of alcohol use or any risk factors for viral hepatitis. Clinical exam was unremarkable. Laboratory data showed Aspartate aminotransferase (AST) or 798 IU/L and Alanine aminotransferase (ALT) of 1254 IU/L, with normal serum bilirubin, alkaline phosphatase and coagulation profile. Serologic tests for viral etiology including Hepatitis A, Hepatitis B, Hepatitis C, Cytomegalovirus, Epstein-Barr virus, and Human immunodeficiency virus were non-reactive. Anti-nuclear antibody, smooth muscle antibody, and anti-double-stranded DNA antibody were unremarkable. Her urine and blood cultures showed no growth. Abdominal ultrasound showed an echogenic liver consistent with hepatic steatosis and no evidence of biliary obstruction. Chest X-ray was normal. Upon review of her medications, patient had started hydroxychloroquine two weeks prior to admission. The medication was discontinued upon admission, after which she continued to improve. At follow up ten days later, she remained asymptomatic and her liver function tests continued to improve with AST of 46 and ALT of 161. DISCUSSION: Acute transaminitis due to hydroxychloroquine is rare. Only four reported cases have been noted per literature review. Mechanism of injury to hepatic cells is unknown however the drug is metabolized in the liver and may alter the metabolism of other drugs. Porphyria cutanea tarda is a disease that may be treated with low doses of hydroxychloroquine. It is known that higher doses of hydroxychloroquine usually greater than 100 mg twice a week can trigger acute liver injury in patients with history of Porphyria cutana tarda. These patients present with sudden onset of fever and marked serum enzyme elevations with increased excretion of porphyrins and photosensitivity. The presented patient in the case report did not have underlying Porphyria cutanea tarda.

Catastrophic consequences of the enormous use of hydroxychloroquine during COVID era on liver and kidney of male albino rats: an in-vivo study

“…In a study in 2019, revealed that higher doses of HCQ usually greater than 100mg twice a week can trigger acute liver injury in patient with history of porphyria cuteana tarda. 29 From our study we found that the GOT, GPT and ALP level is significantly higher in serum as well as in liver and kidney tissues after HCQ exposure, Sekar et al in a study also found a similar effect that a high dose of an insulin mimic medicine sodium orthovanadate led to the increase in GOT, GPT levels in liver tissue. 30 A case reported that a patient with severe COVID-19 after being administrated HCQ, showed a tenfold increase in the level of serum transaminases followed by a rapid decrease after HCQ was withdrawn, the potentiality of HCQ is dose dependent and be associated with hepatotoxicity and the need to monitor liver function during the HCQ therapy.…”

Abnormal Liver Biochemistry Tests and Acute Liver Injury in COVID-19 Patients: Current Evidence and Potential Pathogenesis

“…Preliminary data from a systematic review of 23 studies (including 4 randomized controlled trials and 10 cohort studies) and a parallel, double-masked, randomized, phase IIb clinical trial comprising 81 adult COVID-19 patients showed no association between hydroxychloroquine therapy and abnormalities of liver function tests [77,78]. However, Makin et al [79] reported two cases of acute hepatic failure in patients treated with hydroxychloroquine, and in a recent study there was acute elevation of transaminases (ALT and AST) in four cases that was attributed to the drug [80]. Besides, treatment of COVID-19 patients with hydroxychloroquine and azithromycin have yielded unequivocal findings [51] and there are other cases of acute hepatic failure reported with abnormal liver function tests [74].…”

COVID 19 and liver: An A–Z literature review

“…Only two cases of acute liver failure attributed to hydroxychloroquine were reported [50] . Acute elevation of aminotransferases due to hydroxychloroquine is also rare, and only four cases were reported [51] . Such reactions may be attributed to hypersensitivity.…”