Drug-induced liver injury presenting with hypereosinophilia and increased FDG activity in PET scan

Introduction Drug induced liver injury accounts for 10% of all cases of acute hepatitis. Over 1.000 medication and herbal products have been implicated. The clinical presentation includes a variety of clinical and pathological phenotypes.

Case A 56-year-old patient was referred to our clinic with a 3-month history of cough, a 1-week history of jaundice and fatigue. Additionally, a Thorax Ct scan which revealed 1.5 cm nodular lesion and 1 cm mediastinal lymphadenopathies and a PET Scan with FDG uptake of the lung nodule, spleen and bone marrow and rectum were performed. He denied abdominal pain, fever, nausea, diarrhea and vomiting. In last 3 months he had a travel history to Phuket, New York, Israel and Germany. He started taking several herbals 2 months ago. Laboratory tests revealed eosinophilia (1080 UL), leucocytosis (28,900/mm3), elevated levels of ALT (1994 U/L), AST (1331 U/L), ALP (221 U/L), GGT (182 U/L), bilirubin (Total/direct bilirubin: 10.1/7.4 mg/dL,), INR (2.38), ESR (68 mm/hr). Peripheral blood smear confirmed hypereosinophilia. Serology for viral, parasitic infections and autoimmune hepatitis were negative. Bone marrow and liver biopsy disclosed hypercellular bone marrow with increased eosinophils and erythroid cells and acute hepatitis with centrilobular and bridging necrosis, plasmocyte and eosinophil rich inflammation in the portal zone, respectively.

Conclusion Since all medications usually underreport by the patients, the diagnosis of DILI requires a high degree of awareness and suspicion after excluding other causes of abnormal liver tests TASL.

Publication History

Article published online:
18 January 2023