Hydroxychloroquine Induced Liver Injury

Abstract

Introduction: Hydroxychloroquine is a commonly prescribed medication with antimalarial and anti-inflammatory properties. Drug induced liver injury is a very rarely reported side effect of this medication. Case Report: 62 year old female with history of rheumatoid arthritis, on long term prednisone, presented to the ER with 2 days of arthralgia, generalized weakness, sweats and fever up to 104F. Chest x-ray and CT of the head showed no acute abnormalities. Upon laboratory evaluation, elevated liver function tests with AST 331 and ALT 379 were noted. Bilirubin and ALP were normal. Prothrombin time not elevated. She was admitted for possible sepsis from an unknown source and placed on empiric antibiotics. Upon review of her medications it became apparent that she had started hydroxychloroquine 16 days prior to admission. Hydroxychloroquine was stopped on hospital day 2 due to concern for drug induced liver injury. Her AST and ALT peaked at 798 and 1254, respectively on hospital day 3 and represent a 17 and 20 fold increase above the ULN. Serology tests for HAV, HBV, HCV, CMV, EBV, and HIV were nonreactive. ANA titer had increased from < 1:40 four months ago to 1:80. Anti-histone antibody, ASMA, and anti ds-DNA antibody were unremarkable. There was an increase in urine porphyrin excretion. Abdominal ultrasound showed an echogenic liver consistent with hepatic steatosis and no evidence of biliary obstruction. No growth was seen on blood cultures and antibiotics were de-escalated. AST and ALT began to trend downward on hospital day 4. Her fever had abated by hospital day 6. AST and ALT were down to 228 and 487 respectively at the time of discharge on hospital day 7. She had remained afebrile without any arthralgia at follow up appointment 10 days after discharge. AST and ALT had improved to 46 and 161 respectively. Discussion: We present this case of apparent hydroxychloroquine induced liver injury to add to the fund of knowledge of drug induced liver injuries. Based on our literature review there appears to be four previously reported cases of hydroxychloroquine induced liver injury. Hydroxychloroquine may trigger an acute worsening of porphyria cutanea tarda in susceptible individuals which could present with sudden onset of fever and marked serum enzyme elevations with increased excretion of porphyrins.