Acute Elevation of Liver Enzymes Following Anti-thymocyte Globulin Treatment in a Patient with Aplastic Anemia: A Case Report

Abstract

Background & Objective: Plastic anemia, a rare hematological disorder resulting inpancytopenia, is primarily managed through immunosuppression. Anti-thymocyteglobulin (ATG), a polyclonal antibody derived from equine or lapine sources, is onesuch immunosuppressive treatment. While common side effects of ATG include allergicreactions, thrombocytopenia, headache, and myalgia, more severe but less frequentadverse effects encompass dyspnea and chest pain. The incidence and severity of liverfunction test abnormalities associated with ATG administration remain subjects ofongoing debate; however, most cases present with mild and transient enzyme elevations. Case: We present the case of a 13-year-old male child diagnosed with aplastic anemia (AA) who was admitted to the hematology clinic for ATG treatment. Three days after the initiation of ATG therapy, following the third dose, the patient developed severe hepatotoxicity. The patient experienced symptoms including chest pain, icterus, myalgia, and abdominal tenderness. Laboratory investigations revealed a significant elevation in liver enzymes and serum bilirubin levels. Upon discontinuation of ATG, the symptoms resolved within six days, accompanied by a marked reduction in liver enzymes and bilirubin levels. Subsequently, the patient received the fourth dose of ATG without adverse reactions Conclusion: Our patient developed frank symptomatic hepatitis, manifesting as icterus and right upper quadrant pain. Given the existing literature, this presentation does not appear to be common and warrants increased vigilance