2492 Everolimus-Induced Transaminitis in the Setting of Stage IV Carcinoid Tumor With Liver Metastasis

Abstract

INTRODUCTION: Everolimus may lead to mild and asymptomatic liver enzymes elevation in up to a quarter of the patients taking it, but it rarely leads to symptomatic and significant transaminitis. We describe a case of everolimus induced transaminitis in the setting of stage IV carcinoid tumor with liver metastasis. CASE DESCRIPTION/METHODS: A 58-year-old female with a history of stage IV carcinoid tumor with liver metastasis presented with fatigue and worsening epigastric pain. She was first diagnosed with atypical bronchial carcinoids S/P left lower lobe lobectomy and lymph node dissection. Liver metastasis was diagnosed by biopsy two years later. She was started on everolimus one month earlier, and she reports sharp epigastric pain every time she takes the medication. On presentation, patient's vital signs were within normal limits. Physical exam revealed right upper quadrant and epigastric tenderness. Laboratory findings revealed elevated liver enzymes. AST was 723 U/L, ALT was 580 U/L, and alkaline phosphatase was 513 U/L. Total bilirubin was 1.2 mg/dl. To note, liver function tests were normal two weeks earlier. CT scan of the abdomen showed prominent intrahepatic biliary tracts and gallbladder wall thickening. Hepatitis panel and acetaminophen level were negative. Everolimus was discontinued on presentation. On the second day, bilirubin trended up to 1.6 mg/dl. Afterwards, patient's liver enzymes started to trend down and her bilirubin has normalized. Her abdominal pain has resolved. There was no indication at the time for endoscopic intervention. DISCUSSION: The trend of the liver enzymes is most consistent with a drug- induced liver injury. Patient was recently started on everolimus which was held on presentation. Liver enzymes started to trend down afterwards. AST and ALT were rapidly improving. Bilirubin became normal. It is important to consider everolimus as a cause of hepatocellular injury when other causes are ruled out.