Minocycline

Abstract

Autoimmune hepatitis (AIH) has been associated with various infections and medications including minocycline. We present a rare case of biopsy confirmed autoimmune hepatitis and erythema nodosum in a patient taking minocycline. Case: A 34-year-old woman presented for evaluation of aminotransferase elevations, night sweats, fatigue, myalgias, arthralgias and an erythematous nodule on the left ankle. Symptoms followed a waxing and waning course over 5 months. Persistent malaise and worsening of the skin lesion led the patient to seek evaluation which revealed markedly elevated aminotransferase levels. Her medical history was significant for acne vulgaris for which she took minocycline over the preceding four years, with doses ranging from 100 to 200 mg daily. Physical examination revealed a tender 4 cm area of edematous nodular erythema on the medial left ankle. On presentation, her ALT was 2257 U/L & AST was 1237 U/L and alkaline phosphatase was167 U/L. Bilirubin was normal. Right upper quadrant ultrasound was normal. ANA titer was 1:1280. Antihistone antibodies were also elevated at 2.8. Serum IgG was elevated at 2090 (reference range 751–1560). Anti-smooth muscle antibodies were negative. Viral serologies were negative except for EBV IgM which was elevated (EIA titer 5.82). However, subsequent immunostains from the liver biopsy which were reviewed by the Armed Forces Institute of Pathology were negative for EBV and was consistent with autoimmune hepatitis. Skin biopsy of the patient's ankle was consistent with erythema nodosum. The patient's symptoms resolved within days of stopping her minocycline, and transaminases returned to normal over a four week period and have remained within reference range at 3, 6 and 12 month intervals. Discussion: Minocycline-related autoimmune disorders develop an average of 2 years (range, 3 days to 6 years) after starting drug therapy and typically occur in females under 40 years of age. While minocycline has been reported to cause acute and chronic hepatitis as well as erythema nodosum, this is the first case to our knowledge, in which a patient developed both at the same time and which were biopsy proven. This case serves to underscore the need for monitoring of patients on minocycline with a prompt discontinuation of the medication if erythema nodosum or elevated aminotransferases develop.