A curious case of transaminitis: evaluating LFT abnormalities in oncology patients

Abstract

Background The differential for transaminitis in oncology patients includes ischemia, toxic ingestion, metastases, new malignancy, infection, vascular occlusion, autoimmune, and drug-induced etiologies. Temozolomide, an alkylating agent used first line with concurrent radiation to treat advanced gliomas is associated with improved patient overall and progression-free survival. Temozolamide has no hepatic metabolism and is rarely implicated in drug-induced living injury (DILI) (0.5% cases of a 1000 patient prospective study of DILI). Histologic assessment of temozolamide-associated DILI demonstrated bile duct loss and cholestatic or mixed liver injury pattern. Case Presentation A 62-year-old male with a past medical history of urinary retention with a chronic foley, grade III astrocytoma status-post craniotomy with tumor resection undergoing chemoradiation presented to the ED after outpatient labs demonstrated new liver function test (LFT) abnormalities from a normal baseline 5-days prior. ALT=755, AST=300, ALP=166 and R-factor=13.4 consistent with hepatocellular liver injury. The patient endorsed drinking 2 standard drinks 4 times weekly for 20 years and denied tobacco use, drug use, tattoos, needle exposures, recent travel, or sick contacts. Workup was notable for negative alcohol, salicylate, and acetaminophen levels. Hepatitis A, B, and C serologies, EBV, HSV, VZV, CMV were negative. Anti-nuclear, anti-smooth muscle, and anti-LKM antibodies were negative. Ferritin and ceruloplasmin levels were normal. Right upper quadrant ultrasound demonstrated mild hepatomegaly and hepatic steatosis without focal masses and patent portal veins with forward flow and a normal gallbladder. Temozolamide was considered the likeliest cause of the patient’s transaminitis given the negative workup and 1-day time interval of LFT abnormalities from chemotherapy administration with rapid resolution (by >50% in 2 days and to baseline in 2 weeks) following therapy discontinuation. As such, chemotherapy was discontinued, and the patient continued outpatient radiation without issue. Discussion This case illustrates the importance of generating a wide differential for oncology patients presenting with transaminitis and an appreciation for idiosyncratic drug reactions. Alkylating agents like temozolamide while classically associated with cholestatic patterns of liver injury can also be implicated in hepatocellular liver injury such as in this rare case. However, DILI is a diagnosis of exclusion that requires a broad negative workup.