Drug Induced Hepatitis Progressing to Cirrhosis Case Presentation

Drug Induced Hepatitis Progressing to Cirrhosis

Case Presentation 58 y/o retired business man, with PMH of CAD s/p CABG and ventricular aneurysm repair 14 years ago, was referred b/c of abnormal liver enzymes and jaundice 10/2002 Constitutional symptoms and abnormal ALT and AST. () serologies for viral hepatitis, (-) ANA and unremarkabble US. Medicine withheld a few days 11/2002 Worsening of liver enzymes. Elevation of serum bilirubin 12/2002 Initial visit at University of Miami

Medications: Atorvastatin, Metoprolol Aspirin > 4 years Ramipril since 06/2002 (6 months) Physical exam: (+) icteric sclera Enlarged liver with smooth border, no ascites, no splenomegaly No peripheral edema, no palmar erythema, no telangectasia No encephalopathy

Medications – Atorvastatin – Metoprolol > 4 years – Aspirin – Ramipril since 06/2002 (6 months) Physical Exam – (+) icteric sclera – Enlarged liver with smooth border, no ascites, – no splenomegaly – No peripheral edema, no palmar erythema, no telangectasia – No encephalopathy

Liver Biopsy Centrilobular necrosis, marked mixed cellular infiltration (including polymorphonuclear cells) and “Councilman” bodies

Ramipril Baseline Albumin (g/d. L) (serum) 4. 1 SGOT/SGP T 20/16 Total bilirubin (mg/dl) 0. 6 PT (INR) Ramipril (re)started ER visit Ramipril Meds d/c stopped 5 months 281/501 UDCA 6 months 7 months 8 months 3. 6 3. 4 2. 0 848/1684 1589/907 2570/1484 1. 6 19. 9 23. 2 1. 1 1. 6

Ramipril Baseline Albumin (g/d. L) (serum) 4. 1 SGOT/SGP T 20/16 Total bilirubin (mg/dl) 0. 6 PT (INR) Ramipril (re)started ER visit Ramipril Meds d/c stopped 5 months 281/501 UDCA OLTx 6 months 7 months 8 months 9 months 3. 6 3. 4 2. 0 848/1684 1589/907 2570/1484 462/310 1. 6 19. 9 23. 2 7. 7 1. 1 1. 6 1. 4

Explant