1. Drug Induced Hepatitis Progressing to Cirrhosis

2. 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

3. 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

4. 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

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

6. 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

7. 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

8. Explant