A Case of Lisinopril-Induced Fulminant Hepatic Failure

Abstract

Background: Angiotensin-converting enzyme inhibitors (ACEi) are a generally safe and well-tolerated class of medications. ACEi-induced hepatotoxocity is a rare entity and only few cases of ACEi induce acute hepatic failure (ALF) been reported in literature Case report: 68-year-old female who presented with a day of nausea, vomiting and poor oral intake. She denied fevers, diarrhea, abdominal pain, any sick contacts, or recent travel. Her only medication, Lisinopril, was restarted 3 months ago (was stopped due to acute renal injury). She denied using any other medications or ETOH. No personal or family history of autoimmune conditions or liver disease. Physical exam demonstrated jaundice without abdominal tenderness, or hepatomegaly. Total bilirubin was 21.3 mg/dl, AST/ALT 702/790 IU/L, and Alk phos 269 IU/L (Table 1). Testing was negative for acetaminophen, ethanol, or illicit drugs. Labs were negative for viral hepatitis, EBV, CMV, HSV and VZV BY PCRs. AMA, ASMA, and ALKA antibodies were negative. Ferritin was 6554 ng/ml. HFE gene mutation was negative. Imaging revealed normal liver size and contour with mild heterogeneity of the hepatic parenchyma consistent with hepatitis. Liver biopsy showed marked acute lobular inflammation and a mix of inflammatory cells, marked balloon degeneration, spotty necrosis, acidophil bodies and bridging necrosis over a background chronic injury (Figure 1). PAS stain revealed evidence of hepatocellular injury without evidence of cholestasis and moderate reactive iron deposition in Kupffer cells and hepatocytes and negative Copper stain. Hepatic function rapidly declined resulting in grade III encephalopathy and ALF (MELD score 33 on day 10). She developed an ileus with rapid progression to bowel perforation and septic shock and she expired on admission day 13.Figure 1Conclusion: Drug-induced hepatotoxicity is a rare but potentially fatal cause of ALF. To-date, there are only a few reports of ACEi-induced hepatoxocity with enalapril, captopril and only 3 case reports of lisinopril-induced hepatotoxicity. The mechanism of ACEi-induced hepatoxocity remains unknown. Applying Naranjo's criteria for drug-induced reaction probability to this patient, Lisinopril is the probable cause for her ALF. Although rare, with the rising prescription of ACEi, physicians should be aware of this potentially fatal adverse reaction.Figure 2