Drug-Induced Autoimmune Hepatitis in a Patient Treated With Minocycline: A Rare Adverse Effect

Abstract

Minocycline is an oral broad-spectrum tetracycline antibiotic that is used to treat moderate to severe acne vulgaris as well as certain sexually transmitted infections. Minocycline-induced autoimmune hepatitis can be differentiated from “classic” autoimmune hepatitis by the patient's swift recovery after discontinuing the offending drug and no relapse of the condition upon discontinuation of treatment with corticosteroids. A 31-year-old Chinese woman, with past medical history of acne vulgaris, presented to the Emergency Department with nausea, vomiting, and abdominal pain for the last 3-4 days. She had experienced three episodes of non-bloody, non-bilious vomiting. She described a persistent dull aching pain in the right upper quadrant of the abdomen that had been increasing in intensity, particularly over the last two days. She denied any recent change in her diet. She reported that no one in her household had experienced similar symptoms. She denied any additional recent symptoms. Upon medication reconciliation, it was discovered that the patient had been taking minocycline, on her own and not under medical supervision, for the past three months. Initial laboratory testing was remarkable for significantly elevated transaminase levels with aspartate aminotransferase (AST) of 718 U/L (10-35 U/L) and alanine aminotransferase (ALT) of 1138 U/L (10-55 U/L). An autoimmune workup revealed an elevated antinuclear antibody (ANA) titer (1:160) (<1:40), positive anti-smooth muscle antibodies (ASMA), and the finding of hypergammaglobulinemia (3.2 g/dL) (0.7-1.6 g/dL) with elevated levels of serum immunoglobulin G (IgG) (3176 mg/dL) (700-1600 mg/dL). The bilirubin levels decreased steadily from Day 1 of the hospital admission, but the transaminase levels continued to rise despite discontinuation of the minocycline (Figure 2). On Day 7, she was started on treatment with prednisolone. Also, an IR-guided liver biopsy was performed for the purpose of confirming the diagnosis as well as to assess the degree of liver injury (Figure 3). After two days of treatment with prednisolone, the patient's transaminase levels began to decrease steadily (Figure 2). Physicians should be informed about and suspect drug-induced hepatitis for any individual taking minocycline who presents with elevated LFTs. Physicians who prescribe it to treat acne vulgaris should be aware of this potentially severe adverse effect and stop it immediately when suspicion is raised.2316_B Figure 2. Changes in total bilirubin and alanine aminotransferase (ALT) before and after treatment with prednisolone *Prednisolone, at an initial dose of 50 mg/day, was started on Day 7 of the hospital admission.2316_C Figure 3. Figure 3 (A, B, C, D; left to right). Histopathologic images of the patient's drug-induced hepatitis from liver biopsy A) Piecemeal necrosis. There is chronic inflammation in the portal tracts. H&E stain. 100x. B) Again, there is chronic inflammation in the portal tracts with many plasma cells, lymphocytes, and occasional eosinophils. H&E stain. 400x. C) and D) Spotty necrosis. There is mild chronic inflammation in the portal tracts, as well as ballooning degeneration of hepatocytes indicative of hepatocellular injury. H&E stain. 100x and 400x, respectively.2316_A Figure 1. Abdominal ultrasound There is mild hepatomegaly with increased liver echogenicity.