An Uncommon Complication of Commonly Used Medication

Abstract

Purpose: 73-year male was brought to ER with increasing yellowish discoloration of skin for 3 days; right upper quadrant (RUQ) abdominal pain and confusion for 1 day. Past medical history was significant for diabetes mellitus. The patient was in his usual state of health, when he was hospitalized with fever of 101 F, shortness of breath and cough approximately a week ago. After performing the laboratory work and chest x-ray, right lower lobe aspiration pneumonia was diagnosed and treated with intravenous clindamycin. Patient was discharged home on oral clindamycin on 3rd day. Four days post discharge patient started to notice yellowish discoloration of the eyes and face, gradually increasing in intensity over next 2-3 days and ultimately involving the whole body. On further questioning, the patient's family mentioned some RUQ discomfort with nausea, decreased appetite and increased confusion in the last 24 hours. His blood pressure was 98/63 mmHg, pulse 107 bts/min, respiration 22/min with oxygen saturation of 94% on room air and temperature of 99.5 F. On examination he exhibited grade II encephalopathy and profound jaundice. Abdominal exam was significant for tenderness in RUQ. The rest of the examination was unremarkable. Lab: white cell (WBC) of 11.5 Thou/mm3, with 80% neutrophils, liver function test (LFT) showed bilirubin of 6.9 with direct of 3.43 mg/dl, ALT 1076 IU/L, AST 440 IU/L, alkaline phosphatase 203 IU/L, ammonia 55 umol/L and INR was 2.1. His LFT's were normal prior to this visit. Ultrasound of the liver was reported as normal. Patient was admitted to ICU and clindamycin was held because of possible etiology behind the hepatic injury and it was switched to Zosyn® for broader coverage. Patient conditioned worsened and he developed acute respiratory distress syndrome, for which he was intubated. WBC continued to be elevated, in the face of negative sputum and blood culture, perhaps because of initial antibiotic therapy rendering the cultures negative. On 6th day his LFT's were ALT 437 IU/L, AST 205 IU/L, and bilirubin of 3.6 mg/dl. Serum ferritin, cerruloplasmin level, hepatic and antibody panel came back as normal. There was no history of alcohol use, Tylenol® or any other medication use that could be contributed to be the cause of hepatic failure. As patient continued to be mechanical ventilation dependent and failed multiple weaning trials, support was withdrawn according to his wishes. To conclude, our patient developed liver failure after being treated with clindamycin. Disordered LFT's and synthetic function, which improved after removing the offending agent, would support the diagnosis of clindamycin induced liver toxicity.