P2589 - Cefazolin-Induced DILI

Lisa M. McKinney, DO¹, Rachael Weigle, DO², Zachary Sherrill, DO², Gerald Mank, MD², Suneel Mohammed, MD², Nathaniel Krogel, DO^2
1Blue Ridge Digestive Health, Morganton, NC; ²UNC Health Blue Ridge, Morganton, NC

Introduction: Drug induced liver injury (DILI) is the most common cause of acute liver injury in the US, accounting for approximately 10% of acute hepatitis cases. Cephalosporins, specifically cefazolin, is a commonly used antibiotic and recent studies suggest it is a frequent cause of DILI. It is characterized by a latency period of < 4 weeks after exposure and marked cholestasis. The mechanism of injury is unclear, likely immuno-allergic, but is typically a self-limited moderate/severe course. Below, we present a case of DILI due to administration of intraoperative cefazolin.

Case Description/Methods: A 56-year-old man presenting with an inguinal hernia underwent an uncomplicated

repair. An intraoperative infusion of cefazolin 2 g was given. Four weeks post-op, presented to the emergency room with pruritus, pale stools, and yellowing of skin x 1 week and admitted for further workup. Labs revealed: Total bilirubin 13.8/AST 158/ALT 301/ALP 509. Exam pertinent for jaundice. ANA positive (1:640), negative IgG, AMA, ASMA, viral hepatitis panel. Acetaminophen level < 10. MRI/MRCP revealed incidental small IPMNs. No biliary obstruction or liver disease. CT pancreatic protocol unremarkable. Liver biopsy revealed moderate/severe portal, periportal, and lobular mixed inflammation including lymphocytes, prominent eosinophils, rare proximal cells and apoptotic features consistent with DILI. Patient was referred to hepatology and started on high dose po prednisone with resolution of LFTs.

Discussion: Cephalosporins are common antibiotics used for surgical prophylaxis and previously thought to be a rare cause of DILI. This case not only provides an illustration of cefazolin-associated DILI, but also presents an example of uncertainty about the specific diagnosis. Cefazolin induced DILI has a distinctive clinical presentation but is commonly overlooked. The patient underwent substantial diagnostic testing which can often be unnecessary and/or lead to severe complications. This case demonstrates the need for improved identification of cefazolin-induced DILI given its distinct clinical presentation and better informed consent for patients undergoing surgery who receive intraoperative antibiotics.

LiverTox: Clinical and Research Information on Drug-Induced Liver Injury. 2012-. Cephalosporins.
Alqahtani SA, Kleiner DE, Ghabril M, Gu J, Hoofnagle JH, Rockey DC; Drug-Induced Liver Injury Network. Identification and Characterization of Cefazolin-Induced Liver Injury. Clin Gastroenterol Hepatol. 2015 Jul;13(7):1328-1336.


Disclosures:


Lisa M. McKinney, DO¹, Rachael Weigle, DO², Zachary Sherrill, DO², Gerald Mank, MD², Suneel Mohammed, MD², Nathaniel Krogel, DO². P2589 - Cefazolin-Induced DILI, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.