A Case of Acute Drug Induced Cholangitis Associated with Over the Counter Drug: 759

Purpose: Background and Aims: In daily clinical practice, drug induced liver injury can always be a cause of liver injury in patients taking medications. We reported a rarely drug induced acute cholangitis due to over the counter drug. Case report: A 48-year-old woman with general malaise and progressive jaundice since seven days before admission. She had no history of medicine or drug. A thorough history review revealed that the patient had started prior on over the counter drug: Pabron gold for three times per three days per one month for upper respiratory inflammation. She had no skin rash and erythema. Laboratory investigations showed: T-bil 6.7 mg/dl, D-bil 5.2 mg/dl, AST 182 IU/l, ALT 376 IU/l, LDH 282 IU/l, ALP 936 IU/l, γ-GTP 772 IU/l, ChE 377 U/ml, TP 8.7 g/dl, ALB 4.5 g/dl, T-chol 248 mg/dl, TG 171 mg/dl, blood urea nitrogen 8.3 mg/dl, creatinine 0.7 mg/dl, pancreatic enzymes were within normal limits. Viral hepatitis serology was performed and was negative for HAV, HBV, HCV, HEV, EB virus, and cytomegarovirus. ANA and AMA negative. Abdominal computed tomography excluded pancreatic or hepatic focal lesions. ERCP detected no extrahepatic biliary duct dilatation or stones in the gall bladder. A drug-induced lymphocyte stimulation test for Pabron gold was negative. A liver biopsy revealed edematous and pigmented hepatocytes around the central vein. The inflammatory infiltrate is made of polynuclear neutrophils and a varying number of eosinophils. and presence of interlobular bile duct destruction in the portal tract. These findings might be consistent with acute cholangitis with drug-induced liver injury. Electron micrography revealed that regenerative bile duct related epithelial cell is in an apoptotic process, as inferred from the appearance of condensed polymorphic and fragmented nuclei. Liver function improved after discontinuation of Pabron gold. The patient had presented with drug-associated with over the counter drug Pabron gold for inadvertent rechallenge. In this paper, we report a rare case of acute cholestatic jaundice caused by over the counter drug. Drugs are an important, often unrecognized, cause of acute liver injury.