Multiple drugs

Abstract

Drug-induced liver injury and cardiomyopathy: case report A 22-year-old woman developed drug-induced liver injury and cardiomyopathy following treatment with isoniazid, rifampicin, ethambutol and pyrazinamide for mycobacterium tuberculosis [routes and dosages not stated; time to reaction onset not clearly stated].* The woman was hospitalised with fatigue, mouth ulcers, fevers, weight loss, abdominal pain and erythematous skin lesions for 3 months. Her medical history was significant for systemic lupus erythematosus, Raynaud’s syndrome and antiphospholipid syndrome, which had been well-controlled on prednisone, mycophenolate mofetil [Cellcept] and warfarin. Upon admission, she reported noncompliance to these medications. Initially, a lupus flare was suspected and she was initiated on prednisone. Based on further investigation, she was diagnosed with mycobacterium tuberculosis. She started receiving RIPE regimen consisting of isoniazid, rifampicin, ethambutol and pyrazinamide. Even after receiving two weeks of RIPE regimen, she was observed to have tachycardia, persistent febrile episodes and worsening chest radiographs. Drug resistant mycobacterium tuberculosis was ruled out upon further investigation. RIPE regimen was continued. Laboratory investigations revealed elevated transaminases and bilirubin levels. Ultrasound abdomen compared to CT on admission demonstrated new onset cirrhosis. Liver biopsy showed macro-vesicular steatosis. She was diagnosed with drug-induced liver injury secondary to isoniazid, rifampicin, ethambutol and pyrazinamide. The woman’s RIPE regimen was switched to linezolid, ethambutol and levofloxacin. Thereafter, bilirubin levels improved. Linezolid was then switched to rifabutin. Clinical improvement was noted. However, her tachycardia persisted. 2D echo revealed moderate dilation of the left atrium and ventricle with ejection fraction of 40-45%. She was diagnosed with cardiomyopathy secondary to isoniazid, rifampicin, ethambutol and pyrazinamide. She had congestive heart failure and was initiated on unspecified guideline-directed medical therapy. Eventually, her liver enzymes and tachycardia improved. She was discharged on rifabutin, ethambutol and levofloxacin along with prednisone.