Clinical Case Summary

A 57-year-old woman visited the emergency department due to feeling extremely tired for four weeks. During the examination, she appeared alert but disoriented in space and time. She also had mild jaundice and flapping. The test results showed a total bilirrubin of 12.6mg/dL, direct bilirubin of 5.88mg/dL, ALT 265 IU/L, AST 801 IU/L, alkaline phosphatase 289 IU/L, INR 1.95. An abdominal computed tomography (CT) showed normal liver and no dilation of the bile ducts. The brain CT showed no abnormalities. The diagnosis of acute liver failure was assumed, and the liver transplant team was contacted.
The patient had a medical history of multiple sclerosis and borderline personality disorder. She had been recently hospitalized in a psychiatry unit where an imaging exam identified active lesions of multiple sclerosis. As a result, she underwent treatment with methylprednisolone 1g/day for 5 days and was discharged six weeks before her current visit.
The liver study showed negative results for viral hepatitis; her ceruloplasmin and urinary copper were normal. IgG was increased; ANA had a title of 1/320; ASMA and AMA were negative. A liver Doppler showed patent vessels. A transjugular liver biopsy showed "moderate periportal and severe lobular hepatitis (centrilobular necrosis), with numerous plasma cells, without specific fibrosis - probable autoimmune hepatitis" (Figure 1).
Due to her worsening condition, it was decided to start prednisolone 1mg/kg/day, which showed good clinical and laboratory response. She was discharged with instructions to reduce corticotherapy and to start azathioprine.
There remains a doubt between the diagnosis of autoimmune hepatitis caused by a drug or drug-induced liver injury with autoimmune-like histology. This case is interesting because it is unusual for a corticosteroid to trigger autoimmune pathology. It is also uncommon to prescribe a medication or a similar one that was suspected of causing hepatotoxicity.

Clinical Case Summary

Introduction: Albendazole is a widely used anthelmintic, generally considered safe. While mild liver enzyme elevations are reported, severe drug-induced liver injury (DILI) is rare. We present a case of acute hepatotoxicity after a short course of albendazole, highlighting its potential hepatic risks.
Case presentation: A 13-year-old girl presented with abdominal pain, jaundice, nausea, vomiting, and diarrhea for two days. She had no history of travel, fever, or rash. She had received two doses of albendazole for deworming—15 and 3 days before symptom onset—with no other medication use.
Examination revealed left epigastric tenderness without hepatomegaly. Laboratory findings included markedly elevated liver enzymes (AST 2067 IU/L, ALT 2931 IU/L, ALP 135.58 IU/L, bilirubin 51.3 mg/dL) and prolonged INR (1.86). Viral, autoimmune, and metabolic causes were ruled out. Abdominal ultrasound showed mild hepatomegaly, and CT excluded other pathology.
The Roussel Uclaf Causality Assessment Method (RUCAM) score was 9, indicating a high likelihood of albendazole-induced hepatitis. The patient was treated with supportive care, with gradual improvement and full recovery.
Discussion: DILI is a key differential in acute hepatitis when other causes are excluded. Albendazole hepatotoxicity is rare, mainly reported in long-term therapy for hydatid disease. However, our patient developed severe hepatotoxicity after only two doses, suggesting idiosyncratic or immune-mediated injury. The absence of other risk factors strengthens the causal link.
Conclusion: This case highlights the risk of severe albendazole-induced hepatotoxicity even after short-term use. Given its widespread availability, clinicians should remain vigilant for DILI in children. Liver function monitoring should be considered in at-risk patients, and unnecessary prophylactic albendazole use should be discouraged.

References

1. Chai JY, Jung BK, Hong SJ. Albendazole and Mebendazole as Anti-Parasitic and Anti-Cancer Agents: an Update. Korean J Parasitol. 2021;59(3):189-225.
2. Choi GY, Yang HW, Cho SH, et al. Acute drug-induced hepatitis caused by albendazole. J Korean Med Sci. 2008;23(5):903-905.
3. Ríos D, Restrepo JC. Albendazole-induced liver injury: a case report. Colomb Med (Cali). 2013;44(2):118-120.
4. Garcia-Cortes M, Robles-Diaz M, et al. Drug-induced liver injury: an update. Arch Toxicol. 2020;94:3381.
5. Chalasani NP, Maddur H, Russo MW, et al. ACG Clinical Guideline: Diagnosis and Management of Idiosyncratic Drug-Induced Liver Injury. Am J Gastroenterol. 2021;116:878.

Clinical Case Summary

A 48-year-old man was referred to the hospital after an accident at work because of a five-meter fall, associated with multiple trauma requiring amputation of the left upper limb and prolonged hospitalization in an intensive care unit.
During rehabilitation at the outpatient clinic, he had a mild COVID-19 illness, where progressive cholestasis was detected, so he was referred for study in consultation.
Later he was admitted to the gastroenterology department due to jaundice, choluria, and itching that was difficult to manage. Retrospectively, it was found that cholestasis appeared during intensive care hospitalization and has worsened since then. Magnetic resonance cholangiopancreatography (MRCP) was performed showing a 17mm stricture at the common hepatic duct and multiple irregularities of the intrahepatic bile ducts (IHBD). Human immunodeficiency virus serology was negative and serum IgG4 was normal. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a stricture of the common hepatic duct and multiple IHBD strictures (Figure 1 – bile duct strictures on cholangiography); a plastic stent was placed. Cytology of the dominant stenosis was negative for malignancy. Cholangioscopy showed " biliary casts and inflammatory changes of the entire biliary epithelium from the emergence of the cystic duct to the hilum and IHBD, with edema, friability and membranous exudate, more marked in the hilum, aspects not characteristic of primary sclerosing cholangitis. Two stents were placed in the left and right bile ducts". Biopsies revealed “acute xanthogranulomatous cholangitis” (Figure 2 - foamy histiocytes in bile ducts). The diagnosis of critical illness cholangiopathy with an atypical histology was done and the patient was referred for a transplant consultation.
Since then, two episodes of cholangitis happened and ERCP was performed with the extraction of both stents. It was decided at the transplant meeting to start a pre-transplant study.

References

•Martins, P. and Verdelho Machado, M. (2019) ‘Secondary sclerosing cholangitis in critically ill patients: An underdiagnosed entity’, GE - Portuguese Journal of Gastroenterology, 27(2), pp. 103–114. doi:10.1159/000501405.
•Zhang, J.Q. et al. (2022) ‘Xanthogranulomatous cholangitis mimicking cholangiocarcinoma: Case report and review of literature’, International Journal of Surgery Case Reports, 93, p. 106921. doi:10.1016/j.ijscr.2022.106921.