A case of prolonged cholestatic hepatitis induced by azithromycin in a young woman

Current and New Drugs for COVID-19 Treatment and Its Effects on the Liver

Corona virus disease (COVID)-19 is caused by the novel severe acute respiratory syndrome coronavirus-2 (commonly referred to as SARS-CoV-2). In March 2020, the World Health Organization declared the COVID-19 outbreak a pandemic. Though the target organ for the virus is primarily the lungs, with the recent understanding of the pathobiology of this disease and the immune dysregulation associated with it, it is now clear that COVID-19 affects multiple organ systems. Several drugs and therapies have been tried or repurposed to combat the wrath posed by this disease. On October 22, 2020, the USA Food and Drug Administration approved remdesivir for use in adults and pediatric patients (12 years of age and older). Several of the drugs being tried against COVID-19 have hepatotoxicity as their potential side effect. This review aims to provide the latest insights on various drugs being used in the treatment of COVID-19 and their effects on the liver.

Acute Hepatocellular Injury Associated With Azithromycin

PURPOSE

A report of acute azithromycin-induced hepatocellular injury is described.

SUMMARY

An 83-year-old male was admitted with possible community-acquired pneumonia and received azithromycin and ceftriaxone. After 2 doses of azithromycin, the patient's aspartate aminotransferase and alanine aminotransferase were greater than 3 times the upper limit of normal and continued to rise with subsequent doses. A diagnostic abdominal ultrasound revealed hepatomegaly. Total bilirubin remained within normal limits during the course. Rosuvastatin and fenofibrate were held on admission and were not resumed in the setting of elevated liver enzymes. Rivaroxaban was held in the setting of worsening renal function. Hepatitis serologies were negative. Liver enzymes, international normalized ratio (INR), and activated partial thromboplastin time (aPTT) continued to climb until hospital day 5 when azithromycin was discontinued in response. Liver enzymes, INR, aPTT, and lactate dehydrogenase all decreased from hospital days 6 through 8.

CONCLUSION

A potentially serious liver injury occurred with the initiation of azithromycin and began to resolve quickly after its discontinuation. While cholestatic injury with azithromycin is well described, this is only the third reported case of direct hepatocellular injury.

Intrahepatic cholestasis of pregnancy or azithromycin-induced intrahepatic cholestasis: A case report

RATIONALE

Azithromycin-induced liver injury has been rarely reported in adult individuals, let alone in a pregnant woman. Here, we describe the clinical features and outcomes of azithromycin-induced liver injury in a pregnant woman.

PATIENT CONCERNS

A 30-year-old pregnant woman presented with generalized pruritus and elevated serum bile acid level (123.6 μmol/L) on day 4 of azithromycin administration. A diagnosis of intrahepatic cholestasis of pregnancy was made, and cesarean section was performed immediately. Interestingly, the alanine aminotransferase level (ALT) reached 211.2 U/L on day 9 after azithromycin administration.

DIAGNOSIS

Therefore, drug-induced intrahepatic cholestasis was considered.

INTERVENTIONS

(1) Azithromycin withdrawal after the patient hospitalized. (2) Termination of pregnancy by cesarean section was performed inmmediately to protect the fetus. (3) Silymarin capsules and bifendate are used to protect the liver after liver enzymes elevation was discovered.

OUTCOMES

The liver enzymes recovered within 4 weeks without any symptoms after treatment with silymarin capsules and bifendate, which helps reduce ALT level and protects the liver from further injury.

LESSIONS

A pregnant woman developed azithromycin-induced intrahepatic cholestasis. Physicians should be aware of this side effect of azithromycin, which is widely prescribed.

Azithromycin-induced cholestatic hepatitis

Since its introduction >20 years ago, Azithromycin has been widely used owing to its broad spectrum and good tolerability, especially when used for <7 days. In literature, there are only very few, sporadic reports available of patients developing cholestatic hepatitis following treatment with it. The current case study describes a 69-year old patient, with a medical history that included significant alcohol consumption, who presented with jaundice following a 3-day course of Azithromycin. Following a transjugular liver biopsy, he was managed with a short course of corticosteroids and his liver function gradually improved and finally normalized ~2 months after discontinuation of Azithromycin.

Marked Direct Hyperbilirubinemia due to Ceftriaxone in an Adult with Sickle Cell Disease

Drugs are a significant cause of liver injury. Drug-induced liver injury (DILI) can cause acute hepatitis, cholestasis, or a mixed pattern. Ceftriaxone is a commonly used antibiotic and has been associated with reversible biliary sludge, pseudolithiasis, and cholestasis. A 32-year-old male with sickle cell disease was admitted to the hospital for acute sickle cell crisis. On the second day of hospitalization, he developed cough and rhonchi with chest X-ray revealing right middle lobe infiltrates. Ceftriaxone and azithromycin were initiated. Subsequently, he developed conjugated hyperbilirubinemia and mild transaminitis. His total bilirubin trended upwards from 3.3 mg/dL on admission to 17 mg/dL. It was predominantly conjugated bilirubin, with preadmission bilirubin levels of 3-4 mg/dL. His transaminases were mildly elevated as well compared to previous levels. Extensive workup for bilirubin elevation was unremarkable. Ceftriaxone was switched to levofloxacin and the hyperbilirubinemia improved. On ambulatory follow-up, his bilirubin remained below 4 mg/dL. Ceftriaxone may be associated with marked direct hyperbilirubinemia particularly in sickle cell patients with chronic liver chemistry abnormalities. In the case of elevated bilirubin with concomitant ceftriaxone use, elimination of the offending agent should be considered.