Severe Cholestatic Liver Injury with Fluoroquinolone Use

Abstract

Ciprofloxacin is commonly used for a number of indications.It is occasionally associated with transient elevations in aminotransferases but safety profile is well established in cirrhotic and elderly populations.We present a case of suspected ciprofloxacin-induced liver failure.74 year-old female with unremarkable past medical history presented with new onset fatigue and dysuria. Laboratory testing included normal aminotransferases and coagulation parameters.Urinalysis revealed infection and she was placed on ciprofloxacin 500mg PO BID for 3 days. She re-presented to the hospital 1week later with:aspartate transaminase (AST) 1106, alanine transaminase (ALT) 789, alkaline phosphatase (ALP) 338, and total bilirubin (TBIL) 2.75. Repeated blood and urine cultures showed no systemic infection and there was no history of concomitant herbal supplement or other prescription use.A 2D echocardiogram showed normal systolic function and right sided filling pressures. Serum toxicology screen and acetaminophen level were negative.A comprehensive chronic liver disease workup was performed with results revealing:non-reactive serologies and undetectable nucleic acid level for Hepatitis A, B, C, E, cytomegalovirus,herpes, and Epstein-Barr virus.Autoimmune markers included non-reactive Anti-Nuclear,Anti-Mitochondrial, Anti-Smooth Muscle,Anti-Liver/Kidney Muscle, Anti-Histone Antibodies and serum immunoglobulins.Over the course of 3 days the patient experienced worsening cholestasis and coagulopathy with INR increasing from 1.0 at presentation to 2.5 at day 3.liver biopsy revealed sections of hepatic parenchyma with minimal fatty infiltration and mild to moderate cholestatic changes.The lobules had multifocal chronic inflammation with rare intermixed neutrophils. No plasma cells or granulomas identified, few hepatocytes showed ballooning degeneration,but no hepatocellular necrosis identified.Reticulin and trichrome stains showed focal mild periportal fibrosis.The Council for International Organizations of Medical Sciences/the Roussel Uclaf Causality Assessment Method (CIOMS/RUCAM) scale was 8, outlining a high or definite probability that the ciprofloxacin was the cause of the patient's hepatotoxicity. One week course of prednisone for possible hypersensitivity reaction was tried; however, proved unsuccessful. Palliative care was consulted, and the patient passed away shortly thereafter.Although rare, ciprofloxacin may be associated with severe cholestatic induced liver injury.