Edhi Ahmed I, Hakim Seifeldin, Shams Christienne, Bedi Damanpreet, Amin Mitual, Cappell Mitchell S
Division of Gastroenterology & Hepatology, Department of Medicine, William Beaumont Hospital, 3535 W Thirteen Mile Rd, Royal Oak, MI 48073, USA.
Department of Medicine, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, 3535 W Thirteen Mile Rd, Royal Oak, MI 48073, USA.
Case Reports Hepatol. 2020 Feb 18;2020:2135239. doi: 10.1155/2020/2135239. eCollection 2020.
While erythromycin has caused numerous cases of acute liver failure (ALF), clarithromycin, a similar macrolide antibiotic, has caused only six reported cases of ALF. A new case of clarithromycin-associated ALF is reported with hepatic histopathology and exclusion of other etiologies by extensive workup, and the syndrome of clarithromycin-associated ALF is better characterized by systematic review. A 60-year-old nonalcoholic man, with normal baseline liver function tests, was admitted with diffuse abdominal pain and AST = 499 U/L and ALT = 539 U/L, six days after completing a 7-day course of clarithromycin 500 mg twice daily for suspected upper respiratory infection. AST and ALT each rose to about 1,000 U/L on day-2 of admission, and rose to ≥6,000 U/L on day-3, with development of severe hepatic encephalopathy and severe coagulopathy. Planned liver biopsy was cancelled due to coagulopathies. Extensive evaluation for infectious, immunologic, and metabolic causes of liver disease was negative. Abdominal computerized tomography and abdominal ultrasound with Doppler were unremarkable. The patient developed massive, acute upper gastrointestinal bleeding associated with coagulopathies. Esophagogastroduodenoscopy was planned after massive blood product transfusions, but the patient rapidly expired from hemorrhagic shock. Autopsy revealed a golden-brown heavy liver with massive hepatic necrosis and sinusoidal congestion. Rise of AST/ALT to about 1,000 U/L each was temporally incompatible with shock liver because this rise preceded the hemorrhagic shock, but the subsequent AST/ALT rise to ≥6,000 U/L each may have had a component of shock liver. The six previously reported cases were limited by failure to exclude hepatitis E (4), lack of liver biopsy (2), and uninterpretable liver biopsy (1) and by confounding potential etiologies including disulfiram, israpidine, or recent acetaminophen use (3), clarithromycin overdose (1), active alcohol use (1), and severe heart failure (1). Review of 6 previously reported and current case of clarithromycin-associated ALF revealed that patients had AST and ALT values in the thousands. Five patients died and 2 survived.
虽然红霉素已导致众多急性肝衰竭（ALF）病例，但类似的大环内酯类抗生素克拉霉素仅导致6例有报告的ALF病例。本文报告了1例新的克拉霉素相关性ALF病例，伴有肝脏组织病理学表现，并通过全面检查排除了其他病因，且通过系统评价对克拉霉素相关性ALF综合征有了更好的认识。一名60岁的非酒精性男性，基线肝功能检查正常，因疑似上呼吸道感染，在完成每日2次、每次500mg克拉霉素的7天疗程后6天，因弥漫性腹痛入院，当时AST = 499U/L，ALT = 539U/L。入院第2天，AST和ALT各自升至约1000U/L，第3天升至≥6000U/L，同时出现严重肝性脑病和严重凝血功能障碍。由于凝血功能障碍，原计划的肝活检取消。对肝病的感染性、免疫性和代谢性病因进行的全面评估均为阴性。腹部计算机断层扫描和腹部多普勒超声检查均无异常。患者出现与凝血功能障碍相关的大量急性上消化道出血。在大量输注血液制品后计划进行食管胃十二指肠镜检查，但患者因失血性休克迅速死亡。尸检显示肝脏呈金棕色，有大量肝坏死和窦状隙充血。AST/ALT各自升至约1000U/L在时间上与休克肝不相符，因为这种升高先于失血性休克出现，但随后AST/ALT各自升至≥6000U/L可能有休克肝的因素。先前报告的6例病例存在局限性，包括未排除戊型肝炎（4例）、缺乏肝活检（2例）、肝活检结果无法解读（1例），以及存在潜在混淆病因，包括双硫仑、异拉地平或近期使用对乙酰氨基酚（3例）、克拉霉素过量（1例）、正在饮酒（1例）和严重心力衰竭（1例）。对先前报告的6例和本病例的克拉霉素相关性ALF进行回顾发现，患者的AST和ALT值达数千。5例患者死亡，2例存活。
