Gastroenterology Research, ISSN 1918-2805 print, 1918-2813 online, Open Access
Article copyright, the authors; Journal compilation copyright, Gastroenterol Res and Elmer Press Inc
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Case Report

Volume 10, Number 3, June 2017, pages 202-207

Nafcillin-Induced Allergic Eosinophilic Cholestatic Hepatitis

Figures

Figure 1.
Figure 1. Eosinophilia-course and duration in the patient. Arrow indicates nafcillin start date.
Figure 2.
Figure 2. Liver pathology in the patient. Expansion of portal tracts by lymphocytes, eosinophils, rare plasma cells, and bile duct injury are seen (a: × 20; b: × 60). Focal portal edema with ductular reaction and neutrophilic inflammation is also present (c: × 40). Patchy cholestasis and mild microvesicular steatosis are observed (d: ×40).

Tables

Table 1. Laboratory Data Observed in the Patient
 
Laboratory testPatient (peak value)Normal
White blood cell count (cells/mm3)8,2004,600 - 10,200
Eosinophils (%)20< 6
Eosinophils (cells/mm3)1,640400
Direct bilirubin (mg/dL)12.0< 0.4
Total bilirubin (mg/dL)22.1< 1.2
Alkaline phosphatase (U/L)90820 - 125
AST (U/L)2805 - 50
ALT (U/L)2815 - 50

 

Table 2. Hepatic Injury Reported for Nafcillin and Related Antibiotics [1-24]
 
AntibioticHepatic injury patternReferences
NafcillinPredominantly cholestasis
Eosinophilia
Hypersensitivity		[1-7]
OxacillinHepatitis
Rare cholestasis
Transaminitis
Eosinophilia in majority
Hypersensitivity		[8-18]
Cloxacillin
Flucloxacillin		Cholestatic hepatitis[19-24]

 

Table 3. Salient Features of the Reported Cases of Nafcillin-Induced Hepatic Injury [4-7]
 
Patient informationUnderlying infectionPathogenType of hepatic injuryLiver biopsyOther featuresOutcome
Current case
71/F		Septic knee arthritisS. aureusCholestasisInflammatory cells
Eosinophils
Cholestasis
Steatosis		EosinophiliaCholestasis lasted 3 months
Patient survived
Nafcillin discontinued
69/M [4]Bacteremia
Urosepsis
Infected prosthetic hip		S. aureusCholestasis?NDRaised creatinine
Bilirubin peaked at day 5
No eosinophilia		Abnormalities lasted < 15 days
Patient survived
Nafcillin discontinued
52/F [4]Farunculosis
Cellulitis		Probable S. aureusElevated bilirubinNDRaised creatinine
Bilirubin peaked at day 5
No eosinophilia		Abnormalities lasted < 20 days
Patient survived
Required hemodialysis
Nafcillin discontinued
69/F* [4]Mediastinitis
Pneumonia		UnknownCholestasis?NDRaised creatinine
Bilirubin peaked at days 4 - 5
No eosinophilia		Abnormalities lasted > 15 days
Patient died
Required hemodialysis
Nafcillin discontinued
75/M [4]Infected knee prosthesis
Bacteremia		S. aureusCholestasis?NDRaised creatinine
Bilirubin peaked at days 4 - 5
No eosinophilia		Abnormalities lasted > 40 days
Patient survived
Nafcillin discontinued
63/F [5]CellulitisS. aureusS. aureus suspectedCholestasisInflammatory cells
Eosinophils
Steatosis
Cholestasis		Increased prothrombin time
Bilirubin peaked weeks 2 - 3		Cholestasis lasted > 60 days
Patient survived
Nafcillin discontinued
80/F [6]Septic knee arthritisCoagulase negative staphylococcusCholestasisCentrilobular cholestasis
Mononuclear cells
Eosinophils		Eosinophilia
Bilirubin peaked day 40
Pruritic rash
Diarrhea		Cholestasis lasted > 50 days
Patient survived
Nafcillin discontinued
Prednisone 20 mg/day started
53/M [7]Osteomyelitis
Bacteremia		S. aureusCholestasisDiffuse cholestasis
Infarction
Periportal inflammation		Elevated creatinine
Anemia
Hematuria
Elevated ESR		Cholestasis lasted > 80 days
Treated with ursodiol
Cardiorespiratory arrest on day 84 after nafcillin