Hypersensitivity Reaction to Ursodiol Resulting in Cardiac Arrhythmia

Abstract

Ursodiol (Ursodeoxycholic acid) is a naturally occurring hydrophillic bile acid derived from cholesterol. It is found in small quantities in human bile and in larger quantities in certain species of bear. It has utility in the treatment of both acute and chronic liver disease through multiple mechanisms. We present a case of a hypersensivity reaction to ursodiol resulting in cardiac arrhythmia. A 29 year old male with a past medical history significant for Kugelberg Welander Syndrome, IGG deficiency, and autonomic dysfunction, who was receiving treatment for pseudomonas pneumonia was found to have elevated liver transaminases (alkaline phosphatase 338 IU/L, AST 104 IU/L, ALT 78 IU/L) likely secondary to cholestasis versus drug induced. After excluding other causes of elevated liver function tests, patient was started on ursodiol. Prior to initiation of ursodiol, the patient was in sinus rhythm with vitals significant for temperature of 101.4 deg F and heart rate of 117 beats per minute. Basic metabolic panel was unremarkable. Shortly after the administration of one dose of ursodiol, the patient converted into atrial fibrillation with rapid ventricular response as shown in Figure 1. Physical exam revealed angioedema of the face and upper extremitites as shown in Figures 2 and 3. The patient was given Benadryl and started on a cardizem drip. He returned to sinus rhythm and normal rate within one hour of the initiation of the cardiazem drip, with complete resolution of the angioedema over several days.Figure 1Figure 2Figure 3Ursodiol is a hydrophilic naturally occurring bile acid that is used in the treatment of various liver diseases including primary billary cirrhosis, primary sclerosing cholangitis, hepatitis, cirrhosis, and liver transplant rejection. Multiple mechanisms of action exist for ursodiol including decreasing the toxic endogenous hydrophobic bile acids by a dilutional affect with an increase in the amount of hydrophilic bile acid in cholestatic liver disease. In addition, ursodiol provides cytoprotection of injured bile duct epithelial cells and immunomodulatory effects. Most common side effects of ursodiol include abdominal pain, nausea, itching and diarrhea. In review of literature, there are no documented case reports of a hypersensitivity reaction to ursodiol resulting in cardiac arrhythmia.