Drug Induced Hepatitis

Clinical Presentation 68 year old woman Jaundice Mild epigastric pain Fatigue Pruritus Dark urine/light stools Diarrhea X 41/2 months 6 months prior 7 days

Colonoscopy bx  mild colitis Diarrhea LFTs  nl stools  C&S, O&P, Giardia 2 months Flagyl X 2 weeks 2 months Colonoscopy bx  mild colitis mesalamine (2.4 g/d) 2 months Jaundice

Medications Social History Family history Metoprolol, perindopril, diovan Synthroid Mesalamine Social History No alcohol No recent travel Family history Non contributory

Physical Exam BMI = 32 Marked scleral icterus Mild abdominal tenderness RUQ No hepatomegaly/splenomegaly No ascites, spider angiomata, palmar erythema, asterixis

Laboratory/Imaging Labs AST 1105, ALT 1005 AlkP 312 Tbil 16.7 Dbil 10 INR 1.3, Alb=3.0 Imaging Ultrasound  mildly echogenic liver Serology Acute viral hepatitis A, B serology  NL Autoimmune serology  NL

All meds stopped AST 1105 ALT 1005 AP 312 Tbil 16.7 2 weeks AST 987 ALT 818 AP 324 Tbil> 30 AST 487; ALT 410 AP 292 Tbil> 30 2 weeks Laparoscopy Ursodeoxycholic acid AST 483 ALT 282 AP 254 Tbil 14 3 weeks AST 38 ALT 43 AP 176 Tbil 1.4 6 weeks AST 25; ALT 24 AP 90 Tbil 0.9

Laparoscopy

All meds stopped AST 1105 ALT 1005 Tbil 16.7 2 weeks AST 987 ALT 818 Tbil> 30 AST 487; ALT 410 Tbil> 30 2 weeks Laparoscopy Ursodeoxycholic acid AST 483 ALT 282 Tbil 14 3 weeks AST 38 ALT 43 Tbil 1.4 6 weeks AST 25; ALT 24 Tbil 0.9