Minocycline-Induced Hepatitis

Abstract

Minocyline has been reported to cause autoimmune or hypersensitivity hepatitis after prolonged use. We report a case of hepatitis likely secondary to minocycline use after a short course of therapy for cellulitis. 74-year-old female presented with 3 days of confusion, unsteadiness, multiple oral aphthous ulcers. Prior to arrival, she was being treated by her dermatologist for bilateral lower extremity rash with minocycline for about 16 days. Her extremity rash had completely resolved, while on therapy. Her initial labs showed abnormal LFTs with AST 214, ALT 353, alkaline phosphatase 126, total bilirubin 1.7; Albumin 3.2, PT 12 sec, INR 1.2, platelet counts 67,000, hemoglobin 12.1 and normal white count without left shift or eosinophilia. Minocycline was discontinued upon admission. Stroke was ruled out with brain imaging, blood and urine cultures were negative for infection. Medication review did not show any hepatotoxic or new medications except for minocycline. LFTs and platelet counts progressively worsened until day 6 of hospitalization. Extensive lab tests including autoimmune workup and imaging to evaluate the cause for liver failure and thrombocytopenia were all negative. Liver biopsy could not be performed due to significantly low platelet count. However, from day 7, her platelet counts started improving; by day 10, platelets counts were normal and LFTs started trending down. She was discharged on day 12. A 1 month post discharge follow-up showed normal liver function tests with normal platelet count. Minocycline-induced hepatotoxicity can present either with or without features of autoimmunity. This medication is more commonly used in adolescents and young adults for acne. 2 types of hepatotoxicity are usually present with minocycline-autoimmune or hypersensitivity type. Autoimmune hepatitis type drug related injury was seen associated with associated lupus-like symptoms with positive autoimmune serology after median exposure of 1 year. Hypersensitivity type of reaction can develop more rapidly and is usually associated with eosinophilia, exfoliative dermatitis with median duration of around 35 days in 1 study. Our patient is a caucasian female who had atypical minocycline hepatitis with total exposure for about 16 days, with negative autoimmune serology, eosinophilia, but has oral mucosal ulcers, which resolved rapidly. She also developed significant thrombocytopenia, which resolved after 10 days of discontinuation of medication.