2447 A Case of Daptomycin Causing Drug-Induced Liver Injury

Abstract

INTRODUCTION: Drug-induced liver injury (DILI) is the most common cause of acute liver failure. DILI is rare and characterized by elevated creatinine kinase (CK) and liver enzymes without associated end-organ damage. We present a rare case of daptomycin associated hepatotoxicity without corresponding elevation in CK. CASE DESCRIPTION/METHODS: A 87-year-old man with a history of hypertension, hyperlipidemia, benign prostate hyperplasia, closed fracture of distal lateral malleolus of left ankle, and atrial fibrillation on apixaban presented to the ED from rehab facility with complaints of one day of shortness of breath, cough, diarrhea, and nausea. Patient was a poor historian. He also has had poor oral intake. He was unable to state if he had any prior gastrointestinal problems. No tobacco, alcohol, illicit drug use. On physical examination, patient was noted to have mild purulent drainage on plantar surface of right fifth metatarsal phalangeal joint. A CT scan of foot ruled out osteomyelitis. On admission, labs revealed elevated transaminases with AST 113, likely due to congestive hepatopathy, as per echocardiogram with elevated right ventricular systolic pressure. All other liver enzymes were within normal limits. Blood cultures resulted in Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia and he was subsequently started on vancomycin (due to penicillin allergy). After 7 days of vancomycin therapy, he was switched to daptomycin due to the rising creatinine levels. Next 5 days, LFTs trended up dramatically with the initiation of daptomycin. All non-essential medications were discontinued at this time. LFTs peaked at total bilirubin 1.4, AST 432, ALT 535 and alkaline phosphatase (AP) 161. CK was normal. At this time, daptomycin was discontinued. LFTs started a steep downtrend one day after cessation of daptomycin (Figure 1). The rise in creatinine, total bilirubin, and initial CK levels were temporally related to the initiation of vancomycin infusions (Figure 2). Autoimmune work up and hepatitis panel were all negative. An abdominal ultrasound showed hepatomegaly (16.5 cm) with diffuse hypoechoic texture. Liver doppler showed normal flow. DISCUSSION: Daptomycin induced hepatotoxicity without evidence of elevated CK levels is rare. The pathophysiology is unclear. There is limited literature on DILI without renal failure or rhabdomyolysis in setting of daptomycin use. We only found one case in literature. The long-term sequela has not been fully studied, thus liver enzymes should be monitored closely.