Amoxicillin
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Drug-induced liver injury: 2 case reports In case series, a 3-year-old girl and a 12-month-old girl were described, who developed drug-induced liver injury following treatment with amoxicillin [indications not stated]. Patient 1: A 3-year-old girl developed drug-induced liver injury during treatment with amoxicillin. The girl was hospitalised with worsening abdominal pain associated with emesis and decreased oral intake. On admission, she was found to have significant transaminitis and cholestasis with abnormal coagulation studies. Investigations revealed the following: AST 4911 U/L, ALT 4343 U/L, GGT 151 U/L, total bilirubin 6.4 mg/dL, direct bilirubin 5.4 mg/dL, prothrombin time 15.3 seconds, partial thromboplastin time 26.8 seconds and INR 1.4. She was previously seen 1 month before the admission where her complete blood count, comprehensive metabolic panel and liver function tests were within the normal limits. Two weeks before the admission, she was started on a 10-day course of amoxicillin [route and dosage not stated]. One day before the admission, her mother noticed yellowing of the eyes and face. Her parents denied recent travel, and the child was up to date with her vaccinations. Her father had a fatty liver disease and her mother recently had an inflamed liver from a medication [specific drug not stated]. Further investigations for hepatitis A, B, and C, α-1 antitrypsin, ceruloplasmin, Epstein-Barr virus, cytomegalovirus, adenovirus, urine toxicology, celiac panel and autoimmune hepatitis laboratory test results (antinuclear antibody, anti–liver-kidney microsomal antibody, antismooth muscle antibody, and antisoluble liver antigen) were found to be negative. An abdominal ultrasound revealed hepatomegaly without mass or lesions. There was also diffuse gallbladder wall thickening with trace pericholecystic fluid, no ductal dilatation, and no evidence of cholelithiasis. While admitted, she remained afebrile with stable vital signs. She was started on ursodeoxycholic-acid [ursodiol], omeprazole and vitamin K. Laboratory test results were repeated on day 1 of admission which revealed the following: AST 3826 U/L, ALT 3840 U/L, GGT 135 U/L, total bilirubin 7.5 mg/dL, direct bilirubin 6.6 mg/dL, prothrombin time 15.3 seconds, partial thromboplastin time 31.6 seconds and INR 1.7. Complete blood count and CMP were unremarkable, including creatinine of 0.22 mg/dL and platelet count of 227 × 109/L. Due to the increasing INR, the dose of vitamin K was increased; however, her INR continued to increase at which time the case was discussed with a regional liver transplant center and it was determined that the patient would benefit from liver biopsy and prompt pathology reading for the possible start of treatment. On transfer, liver biopsy was performed, and the findings showed features of acute and chronic hepatitis. The pathologist further noted plasma cells were conspicuous, a nonspecific finding, and can be seen in a variety of acute and chronic hepatitis including drug injury, infection and autoimmune hepatitis.
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