2216 Toxic Epidermal Necrolysis and Drug-Induced Liver Injury Secondary to Oseltamivir

Abstract

INTRODUCTION: Multiple antibiotics have the well documented adverse reactions of Stevens-Johnson syndrome, toxic epidermal necrolysis, and liver injury. Oseltamivir is not known to cause any of the above reactions. We present a patient who suffered both toxic epidermal necrolysis and drug induced liver injury (DILI) secondary to oseltamivir. CASE DESCRIPTION/METHODS: A 40-year-old female with systemic lupus erythematosus (SLE) on hydroxychloroquine and azathioprine for several years presented with community acquired pneumonia and rash concerning for Stevens-Johnson syndrome (SJS). She was also found to have newly elevated liver chemistries in a hepatocellular pattern. Her only new medication was oseltamivir which had been started 48 hours prior to presentation for empiric treatment of influenza. She was transferred to our tertiary care academic medical center burn unit for further management of SJS which eventually progressed to toxic epidermal necrolysis (TEN) (confirmed via dermatopathology). On arrival to our institution, her pattern of abnormal liver chemistries evolved into that of a cholestatic hepatitis with a peak conjugated hyperbilirubinemia of 16.7mg/dL, alkaline phosphatase of 1087 U/L, AST of 400 U/L, and ALT of 708 U/L. Her TEN started to improve with supportive care and cessation of oseltamivir. She underwent MRCP which revealed possible bile duct stricturing without biliary ductal dilatation. Her ANA was positive with a titer of 1:640, anti-smooth muscle antibody was negative, anti-mitochondrial antibody was negative, and IgG level was within normal limits. She underwent liver biopsy which was consistent with drug induced liver injury. Her liver chemistries eventually started to improve and she was discharged from the hospital with continued improvement on follow up. DISCUSSION: Oseltamivir is an antiviral sometimes used for influenza infection. Very few reports exist regarding oseltamivir’s association with SJS/TEN, and even less on its association with liver injury. Our case is unique in that a patient developed both TEN as well as drug induced liver injury secondary to oseltamivir which are rare but important differential diagnoses to be aware of for patients who develop rash or elevated liver enzymes while being treated with oseltamivir.