Azathioprine
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Cholestatic hepatitis in an elderly patient: case report A 73-year-old man developed cholestatic hepatitis during treatment with azathioprine. The man presented to an emergency department with vomiting, fever, pruritus, and dark urine for 7 days. Fifteen days prior to presentation, he received azathioprine 50mg once daily [route not stated] in addition to prednisone for graft rejection following keratoplasty. This was his first exposure to azathioprine and a period of 7 days preceded his fever and jaundice. His other medications included atorvastatin and losartan. Examination revealed prominent jaundice and his body temperature was 100.4°F. His abdomen was soft with some tenderness. Investigations showed bilirubinuria, conjugated hyperbilirubinaemia, elevated ALP and transaminases, and a prolonged prothrombin time. He also had mild eosinophilia. Azathioprine was withdrawn, along with atorvastatin. He received antibacterials and was discharged after 72 hours. He presented with low-grade fever, jaundice with pale stools, and severe pruritus, 35 days later. His transaminases and prothrombin time had normalised, his ALP level had improved, but his hyperbilirubinaemia had worsened. His serum angiotensin-converting enzyme level was elevated and a liver biopsy revealed perivenular hepatocanalicular cholestasis with mild inflammation of the lobes. From day 35, he received ursodeoxycholic acid and hydroxyzine. He was afebrile by day 42 and discharged. His jaundice and pruritus gradually subsided. Follow-up at 4.5 and 7.5 months revealed he was asymptomatic and liver function tests were normal except ALP which was trending downwards. During the fourth month, his atorvastatin was reinitiated and there were no unfavourable events. Author comment: "A final diagnosis of probable azathioprine-induced hepatitis with prolonged cholestasis was made." Moses V, et al. Azathioprine induced cholestatic hepatitis. Indian Journal of Pharmacology 43: 733-735, No. 6, Dec 2011. Available from: URL: http:// 803066579 dx.doi.org/10.4103/0253-7613.89840 - India
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Reactions 4 Feb 2012 No. 1387
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