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Hepatotoxicity and immune-related hepatitis: case report A man in his 60s [exact age at onset not stated] developed hepatotoxicity during treatment with ampicillin and fluconazole and immune-related hepatitis during treatment with cemiplimab [not all routes, dosages and indications stated; durations of treatment to reactions onset not stated]. The man, who had a 16-year history of IgG multiple melanoma (MM), presented to a dermatology clinic with forehead lesion. He was receiving dexamethasone and daratumumab for MM. Following various investigations he was diagnosed with metastatic cutaneous squamous cell carcinoma (cSCC) along with new hypermetabolic preauricular lymphadenopathy. Three years prior, he had two brief mild elevations of AST and ALT, which had spontaneously resolved. However, at current presentation, he had mildly elevated alkaline phosphatase (ALP) that was thought to be secondary to his MM. Treatment with IV cemiplimab 350mg every 3 weeks was initiated. Three months following initiation of cemiplimab, moderate elevations of AST and ALT along with further increase in ALP levels were noted. Additionally, the γ-glutamyl transpeptidase level was increased confirming the liver source of the ALP. A CT scan showed improved lung nodules and lymphadenopathy. At that time, his concomitant medication included ampicillin and fluconazole that might have contribute to hepatotoxicity. Hence, the man’s treatment with ampicillin and fluconazole was discontinued leading to partial improvements in the liver function tests. Liver ultrasound and esophagogastroduodenoscopy with portal hypertensive gastropathy, confirmed the diagnosis of liver cirrhosis. The hepatologist felt that the chronic liver cirrhosis was caused by alcoholic steatohepatitis (due to a history of alcohol consumption for 20 years) and nonalcoholic steatohepatitis (due to MM and mitral stenosis). A year after initiation of cemiplimab, it was discontinued and his AST and ALT normalised that suggested mild component of immune-related hepatitis. Further, his ALP level also improved. Treatment with carfilzomib was added to dexamethasone and daratumumab due to increasing M spike and worsening of anaemia and his MM improved. However, 15 months following initiation of cemiplimab, he developed multiorgan failure in the setting of liver cirrhosis leading to hepatorenal syndrome with kidney failure and anasarca with pleural effusions. He died of multiorgan failure. . Marukian NV, et al. Metastatic cutaneous squamous cell carcinoma responsive to cemiplimab in a patient with multiple myeloma. JAAD Case Reports 6: 819-821, No. 9, Sep 803501469 2020. Available from: URL: http://doi.org/10.1016/j.jdcr.2020.06.036

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Reactions 19 Sep 2020 No. 1822