Fulminant Liver Failure Secondary to Doxycycline Requiring Rescue Liver Transplantation

Abstract

Introduction: Doxycycline is a broad-spectrum antibiotic of the tetracycline family that inhibits bacterial protein synthesis by binding the 30S ribosomal subunit. Due to its effectiveness in treating wide range of infections, doxycycline is one of the more commonly prescribed antibiotics in the United States. The hepatotoxicity of tetracyclines has been well characterized; however, only a few cases of fulminant liver failure attributed to doxycycline exist in English literature. We present a rare case of doxycycline induced liver failure requiring rescue liver transplantation. Case Report: A 36-year old female with past medical history only significant for a resected medulloblastoma presented with a two week history of fatigue, malaise, and jaundice. She had been prescribed doxycycline to treat a ureaplasma urealyticum genitourinary infection one week prior to her symptoms starting. On arrival, laboratory investigation revealed total bilirubin 12.8 mg/dL, AST 2620 IU/L, ALT 1990 IU/L, ALP 143 mg/dL. A complete inpatient workup for acute liver failure with laboratory and imaging studies was unrevealing and the patient's liver indices progressively worsened. Transjugular liver biopsy was performed which revealed massive hepatocellular necrosis with pigmented macrophage infiltrate and early fibrosis. The patient progressed to fulminant liver failure and received rescue orthotopic liver transplantation ten days after admission. The Roussel Uclaf Causality Assessment Method (RUCAM) score for this case was 8, indicating probable drug induced liver injury. Discussion: Drug induced liver injury is a commonly encountered clinical entity accounting for up to 10% of cases of acute hepatitis. The diagnosis pertaining to drug induced liver injury can be difficult and is a diagnosis of exclusion. Doxycycline is known to be hepatotoxic and generally produces mild transaminase elevation that is self-limiting. To our knowledge, less than five cases of doxycycline induced liver failure exist in reported literature. We present an unusual case of fulminant liver failure attributed to doxycycline, following extensive negative workup for alternative explanation. When suspecting drug induced liver injury, progressive worsening of liver function despite cessation of the offending drug should prompt evaluation for liver transplant.