Details

Autor(en) / Beteiligte

• Bush, Allison
• Pak, Kevin
• Church, Tyler
• Sadowski, Brett W.
• Torres, Dawn

Titel

HEaV-y Supplement Use: Or Is It?: 2402

Ist Teil von

• The American journal of gastroenterology, 2018-10, Vol.113 (Supplement), p.S1340-S1341

Ort / Verlag

New York: Wolters Kluwer Health Medical Research, Lippincott Williams & Wilkins

Erscheinungsjahr

2018

Beschreibungen/Notizen

• When the evaluation of newly elevated liver enzymes is unrevealing, common diagnosis of exclusion is drug induced liver injury (DILI). While difficult to definitively diagnose, DILI is determined by establishing a temporal correlation of an exposure to a hepatotoxic substance and a clinical presentation consistent with hepatitis, then managed with drug discontinuation and monitoring. We describe a case of presumed DILI that necessitated reassessment due to clinical deterioration. A 39-year-old Active Duty Marine, with prior active heavy supplement use, presented with one-week history of jaundice, fatigue, dark urine, acholic stools, and pruritus. History was significant for travel to Vietnam, India and a recent return from Taiwan one week prior. A liver function panel was significant for an elevation of his transaminases: AST and ALT were 236 U/L and 618 U/L, and a total bilirubin of 18.6 mg/dL. A right upper quadrant ultrasound was performed, which revealed mild hepatomegaly and increased periportal echogenicity, without biliary obstruction or thrombosis. HBsAg, Anti-HBc IgM, Anti-HAV IgM, and HCV antibodies were negative. Further work up was unremarkable with normal alpha-1-antitrypsin, ceruloplasmin, alcohol, acetaminophen, immunoglobulins, ANA, SMA, and AMA. With inconclusive findings, down-trending transaminase levels, and clinical stability, the patient was given an exclusionary diagnosis of DILI secondary to heavy supplement use. He was managed with supportive therapy for his pruritis and recommended that he discontinue supplement use. Two weeks later, at his follow-up visit in the gastroenterology clinic, the patient reported worsening jaundice with new chills, fatigue, mental fog and a fifteen-pound weight loss. Liver biopsy results showed evidence of acute cholestasis without signs of treatable causes of liver injury. Additional laboratory testing was revealed that the patient had a positive Hepatitis E Virus Ab IgM, consistent with an acute hepatitis E infection. Over the next two months the patient recovered with resolution of symptoms. Hepatitis E Virus (HEV) is a more common cause of acute viral hepatitis in the developing world than in industrialized countries, although its true prevalence in the United States (U.S.) is likely underestimated. In the U.S., a small portion of cases of suspected DILI are eventually found to have acute hepatitis E. Both HEV Ab IgM and IgG should be considered in patients with a provisional diagnosis of DILI.