A Case of Doxycycline and Cefuroxime-Induced Liver Injury

Abstract

Introduction: Drug induced liver injury (DILI) is a relevant topic in clinical practice. Doxycycline and Cefuroxime are commonly used and well tolerated. We describe a case of DILI from Doxycycline and Cefuroxime. Case presentation: A 56 year old male presented with fever. Past history was significant for a tick bite treated for possible Lyme disease with Doxycycline which he did not tolerate after 7 days followed by Cefuroxime for 2 weeks. He had another 2 week course of Cefuroxime after another tick bite. He had no relevant family history. He drank alcohol once a week. Physical examination was unremarkable. Laboratory tests revealed ALT: 704 U/L, AST: 612 U/L, total bilirubin: 1.9 mg/dL, direct bilirubin: 0.6 mg/dL, indirect bilirubin: 1.3 mg/dL, ALP: 589 U/L, GGT: 848 U/L, INR: 0.9 and albumin: 3.7 g/dL. EBV IGM antibody was equivocal at 36.8 U/ml. Blood cultures and serologies for viral hepatitis, Lyme disease, CMV, Babesia microti and Anaplasma phagocytophilum were negative. Abdominal ultrasound was negative for biliary dilation. A liver biopsy revealed portal and lobular chronic inflammation with mild cholestasis compatible with DILI. EBV in situ hybridization was negative. His liver function tests started to improve within days after stopping Cefuroxime. Discussion: Doxycycline is among the class of tetracyclines that can increase the level of unconjugated bilirubin. It has been shown to be safer and less hepatotoxic than Tetracycline. Doxycycline is reported to cause acute liver failure, hepatocellular necrosis, and cholestasis. Cefuroxime is a second generation cephalosporin that has also been reported to cause cholestasis, ischemic hepatitis, and liver failure. We believe that our patient suffered from Doxycycline and Cefuroxime DILI. The 3 courses of antibiotics could have been the culprit for the portal and lobular chronic inflammation on biopsy. There are few case reports about the hepatotoxic effects of Doxycycline and Cefuroxime. Physicians should be mindful of this adverse drug event since these are commonly used medications.