Hydralazine-Induced Liver Injury in a Recovering Ischemic Hepatitis Patient

Abstract

Introduction: A 77-year-old woman presented to the emergency department with a 2-day history of nausea and vomiting, with no other associated gastrointestinal symptoms. Her past medical history included diabetes mellitus type 2, hypertension, atrial fibrillation, dilated cardiomyopathy, coronary artery disease, and history of non ST elevation myocardial infarction. Her home medications included aspirin, clopidogrel, warfarin, digoxin, metoprolol ER, losartan, simvastatin, isosorbide dinitrate, furosemide, and spironolactone. Initial physical exam showed blood pressure of 170/80 mmHg with a heart rate of 69 beats/minute, otherwise unremarkable. Initial lab work-up was significant for supra-therapeutic INR of 3.6, with slightly elevated troponin I and creatinine of 0.06 ng/ml and 1.4 mg/dl, respectively. The rest of the lab work-up was within normal limits. The patient was admitted to the medicine floor. However, a few hours after admission, her atrial fibrillation went into rapid ventricular response, associated with hypotension. Cardiac enzymes began to trend up along with worsening of her renal and hepatic enzymes. Her INR remained supra-therapeutic despite holding coumadin and giving vitamin K. The patient was transferred to the MICU for heart rate control and close monitoring. She was started on metoprolol and received a bolus of normal saline. During day 1 of the MICU stay, losartan, simvastatin, and diuretics were held while aspirin, clopidogrel, and isosorbide dinitrate were continued. In the following 2 days, there was worsening of tissue perfusion. Lab work up indicated AST 514 IU/L, ALT 391 IU/L, INR >9, Creatinine 3.8 mg/dL, and troponin I 0.19 ng/ml; therefore, digoxin was also held. Once the patient achieved hemodynamic stability, she was started on hydralazine. On day 4, renal function, cardiac, and hepatic enzymes improved significantly. However, 24 hours after starting hydralazine, transaminases began to trend up again, reaching a maximum of AST and ALT of 359 and 525 IU/L, respectively. Other possible causes were ruled out, as her viral hepatitis markers, anti-histone antibody, anti-nuclear antibody, and anti-double strand DNA were all negative. After thorough review of all medications, hydralazine was held with subsequent improvement in transaminases. The patient was seen a month later following her discharge, and all her lab work improved to baseline.