Severe Cholestatic Drug-Induced Liver Injury With Cephalosporin Use

Abstract

Drug-induced liver injury (DILI) is a phenomenon that occurs with nearly all classes of medications. Cholestatic DILI represents a fraction of these cases and can present as bland cholestasis, cholestatic hepatitis, secondary sclerosis cholangitis, and vanishing bile duct syndrome. Risk factors have been identified for cholestatic DILI, including older age, genetic determinants, and certain medications such as amoxicillin-clavulanate. Here, we describe a complicated case of severe cholestatic DILI secondary to cephalosporin use. A 27-year-old female presented to the hospital initially with fever and abdominal pain for four weeks after an emergency C-section for pre-eclampsia and hemolysis, elevated liver enzymes, lowered platelets (HELLP) syndrome. She was found to have a retroperitoneal abscess and underwent bilateral drain placement. She was initially started on cefazolin, and then coverage was broadened to cefepime. Shortly after, alkaline phosphatase (ALP) rose and peaked at 3498 IU/L, with aspartate aminotransferase (AST) and alanine transaminase (ALT) elevated at 274 IU/L and 122 IU/L, respectively. Extensive testing for secondary causes and a liver biopsy were consistent with DILI. Liver enzymes downtrended with the cessation of cefepime. This case report highlights that prompt recognition of the culprit medication is paramount to recovering normal liver function.

Unveiling the Uncommon: Co-occurrence of Drug-Induced Liver Injury and Erythema Multiforme Following Cefazolin Administration

“…It can manifest over a wide spectrum of diseases starting from mild disease with abnormalities in the liver function tests only, to severe disease ranging from fibrosis to acute liver failure [10]. DILI can be caused by a myriad of drug classes including oral hypoglycemic agents, statins, acetaminophen, antiretrovirals, antibiotics, and dietary supplements [11]. Antibiotics are the most common class of medications responsible for DILI, constituting 45.4% of the total cases [12].…”

“…Hepatotoxicity caused by antibiotics is usually idiosyncratic [10]. Most commonly involved antibiotics include amoxicillin-clavulanate, cephalosporin, isoniazid, and nitrofurantoin [11]. Cefazolin has been found to be the sixth most common medication associated with DILI according to Drug-induced Liver Injury Network (DILIN)-an ongoing prospective study in the US [13].…”

“…More importantly, DILI is a clinical diagnosis [10]. Liver biopsies are not indicated but can be performed to look for the type and severity of injury [11]. Management for DILI consists of withdrawal of the causative agent, avoiding rechallenge with the medication, and symptomatic treatment.…”

“…Management for DILI consists of withdrawal of the causative agent, avoiding rechallenge with the medication, and symptomatic treatment. It is a self-limiting disease that resolves after drug cessation, however, in some patients, it progresses to acute liver failure or cirrhosis [11].…”