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 Ramipril > 4 years 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

Enlarged liver with smooth border, no ascites, no splenomegaly Medications Atorvastatin Metoprolol Aspirin Ramipril > 4 years 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 (re)started ER visit Meds d/c Ramipril stopped Ramipril UDCA   Baseline 5 months 6 months 7 months 8 months Albumin (g/dL) (serum) 4.1 3.6 3.4 2.0 SGOT/SGPT 20/16 281/501 848/1684 1589/907 2570/1484 Total bilirubin (mg/dl) 0.6 1.6 19.9 23.2 PT (INR) 1.1

Ramipril (re)started ER visit Meds d/c Ramipril stopped Ramipril UDCA OLTx   Baseline 5 months 6 months 7 months 8 months 9 months Albumin (g/dL) (serum) 4.1 3.6 3.4 2.0 SGOT/SGPT 20/16 281/501 848/1684 1589/907 2570/1484 462/310 Total bilirubin (mg/dl) 0.6 1.6 19.9 23.2 7.7 PT (INR) 1.1 1.4

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