Secondary Sclerosing Cholangitis After Antibiotic-Related Drug-Induced Liver Injury

Document Type

Article

Abstract

Introduction:

Literature on secondary sclerosing cholangitis (SSC) due to drug-induced liver injury (DILI) is limited to case studies of antineoplastic immunotherapy, herbal drugs, sevofluorane, and moxifloxacin. We present a case of SSC after DILI from amoxicillin-clavulanate, metronidazole, and ceftriaxone use.

Case Description/Methods:

A 58-year-old male admitted for diabetic ketoacidosis and acalculous cholecystitis received percutaneous cholecystostomy and fluid culture grew klebsiella, enterococcus, and E. Coli. He was treated with amoxicillin-clavulanate, metronidazole and ceftriaxone. Liver function tests(LFT) showed total bilirubin (2.84 mg/dl), ALP (285 IU/L), AST (192 IU/L), and ALT (140 IU/L) which peaked and stabilized. After 1 month, he presented with jaundice and elevated LFT with rising bilirubin and LFT’s. RUCAM score 6 pointed to amoxicillin-clavulanate as the probable cause for liver injury. Magnetic resonance cholangiopancreatography (MRCP) and Endoscopic retrograde cholangiopancreatography (ERCP) did not show any stone, dilation, stricture or mass. His first liver biopsy showed active hepatitis, cholestasis, and no fibrosis, consistent with DILI from antibiotic exposure. Four months later, MRCP revealed obstruction of left hepatic duct with abrupt cutoff and intrahepatic biliary dilatation (Figure 1a, 1c). ERCP showed left-main hepatic duct stricture and stent was placed. Total bilirubin rose to a peak of 19. Biopsy ruled out IgG4 disease (PSC) and cholangiocarcinoma. Chronic liver disease etiology testing were negative. He received a 4-month taper of steroids with modest improvement in bilirubin. Eleven months from initial injury, liver biopsy showed cholestasis, bile duct injury with focal lymphocytic cholangitis, and duct loss with scar, suggestive for sclerosing cholangitis (Figure 1b, 1c). He developed decompensated cirrhosis but deemed not a candidate for transplant due to age and comorbidities. He opted for hospice and passed away 2 years from initial presentation.

Discussion:

Only 3 cases from 1 retrospective study cites association between amoxicillin-clavulanate and SSC. This case is unique due to the rapid progression of sclerosing cholangitis with imaging revealing biliary strictures that were not present 5 months earlier. Management of DILI and subsequent SSC includes removing offending drug. This highlights the rapid progression of SSC toward end-stage liver cirrhosis within 1 year of initial insult delineating the importance of early identification SSC due to antibiotics.

DOI

10.14309/01.ajg.0000958456.14623.af

Publication Date

10-1-2023

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