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Elevated liver enzymes following off label use: case report A 77-year-old woman developed elevated liver enzymes during off label treatment with hydroxychloroquine for COVID-19. Additionally, she received off label therapy with azithromycin for COVID-19. The woman, who had a diabetes presented to the transplant center with decompensated cryptogenic cirrhosis. Subsequently, she underwent combined liver-kidney transplantation. Thereafter, she started receiving mycophenolate mofetil, prednisone and tacrolimus. Postoperatively, her liver enzyme levels were normal and she no longer needed dialysis. She was discharged 12 days after the transplantation (POD 12). On POD 13, she underwent rehabilitation sessions with an occupational therapist (who was later found to be COVID-19 positive). Thus, her mycophenolate mofetil was discontinued, but tacrolimus and prednisone were continued. The following morning (on post-COVID-19 exposure day 10), she underwent percutaneous drainage of the perinephric abscess and the next day, she also testes COVID-19 positive and she was hospitalised. Subsequently, a five-day treatment course of off label oral hydroxychloroquine at a dose of 400mg was scheduled for COVID-19. However, she had a significant elevation in liver enzymes including aspartate aminotransferase, alanine aminotransferase and alkaline phosphatase. During the course of hospitalisation, she received various concomitant anti-biotics. The woman’s hydroxychloroquine dose was reduced to 200mg, but later discontinued (on post-exposure day 13). Following cessation of hydroxychloroquine, her liver enzyme levels improved. For further treatment of COVID-19, off label therapy was started with IV azithromycin 500mg followed by oral azithromycin 250mg. Thereafter, she remained asymptomatic and was discharged home. Mahendraraj K, et al. First report of novel coronavirus infection following abdominal organ transplantation in North America during the covid-19 pandemic. Transplantation 803519154 104 (Suppl.): S321 abstr. P-9.12, Sep 2020. Available from: URL: http://doi.org/10.1097/01.tp.0000700140.11520.0d [abstract]

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Reactions 5 Dec 2020 No. 1833