A Case-Report of Drug-Induced Mixed Liver Injury Resulting From Cefepime Exposure

Abstract

A 99-year-old African-American male presented to the hospital with severe sepsis secondary to a urinary tract infection. Upon initial presentation he was tachycardic, hypotensive and had leukocytosis. While he had signs of acute kidney injury, no signs of acute liver injury were present with his alanine transferase (ALT) and amino transferase (AST) levels measuring at 22 and 44 U/L, respectively. During the treatment course the patient began to show signs of clinical improvement. Despite this, his ALT and AST began to increase on day 2 of treatment and reached their peak of 210 and 239 U/L on day 4. Cefepime-induced liver injury was suspected and cefepime was discontinued. Upon cefepime discontinuation, liver enzymes downtrended and gradually returned to normal. No other likely medication causes of liver injury could be identified and alternative medical causes were ruled out. The lack of an alternative cause and the temporal relationship of cefepime use to hepatic dysfunction support the diagnosis of cefepime-induced liver injury. The patient’s Roussel Uclaf Causality Assessment Methods score was 7, indicating this was a possible case of cefepime-induced liver injury, and the Naranjo Nomogram score was 5 indicating this was a probable case of cefepime-induced liver injury. While cefepime-induced liver injury is rare, clinicians should be cognizant of the potential for this adverse effect if liver enzyme elevation is detected during cefepime therapy and other common causes have been ruled out.

Cefepime-induced Acute Liver Injury in a 5-Year-old Boy

“…Like our patient, the liver enzymes in these cases were normal on admission and gradually downward trended to normal after stopping cefepime. 4,5 Additionally, there does not appear to be a pattern in hepatocellular versus cholestatic liver injury among our case and these 2 cases in the literature. 4,5 Finally, regarding physical signs of liver injury, our patient had jaundice and abdominal pain.…”

“…The 93-year-old patient had jaundice and tea colored urine, but the 99-year-old patient had no evidence of liver injury on examination. 4,5 In conclusion, this case represents an unusual presentation of liver injury after only 2 doses of cefepime. Our patient had extremely elevated transaminases in addition to elevated total and direct bilirubin with jaundice and right upper quadrant pain on physical examination, all suggestive of clinically relevant liver injury.…”

“…3 Two other case reports of cefepime-induced acute liver injury were found in the literature, a 93-year-old man admitted to the intensive care unit with polymicrobial ventilator-associated pneumonia found to have a cholestatic liver injury and a 99-year-old man with urosepsis and mixed hepatocellular and cholestatic liver injury. 4,5 These patients had peak ALT of 86 and 210, AST of 104 and 239, ALP of 515 and 94 and total bilirubin of 9.53 and 0.9, respectively. 4,5 These values are overall relatively low compared to our patient, who had highly elevated transaminases.…”

“…4,5 These patients had peak ALT of 86 and 210, AST of 104 and 239, ALP of 515 and 94 and total bilirubin of 9.53 and 0.9, respectively. 4,5 These values are overall relatively low compared to our patient, who had highly elevated transaminases. Like our patient, the liver enzymes in these cases were normal on admission and gradually downward trended to normal after stopping cefepime.…”

“…3 Our literature review identified only 2 published case reports of patients with acute cefepime-associated DILI, both in geriatric patients. 4,5 Here we report the case of a 5-year-old boy with cefepime-induced acute liver injury. To our knowledge, this is the first reported pediatric case of a cefepime-associated DILI.…”