Case Presentation
The patient was a 78 year old man who had successfully been treated by thrombolysis (Alteplase, Boringer-Ingelheim) before undergoing angiography and angioplasty on the LAD with a drug eluting stent the next day. His only risk factor for coronary disease was a previous history of smoking. Echocardiography demonstrated the following results:
EF=25-30%,LARGE LV CLOT (16*7 mm2) in apex,no significant valvular disease
The patient was discharged in a stable condition with normal lab findings and prescribed the following medications:
Tab ASA 80 mg/daily,tab Clopidogrel 75mg/daily(sanofi),tab carvedilol 6.25BD,Tab captopril25 mg BD,tab pentoprazol 40 mg/daily ,tab warfarin 5mg /daily
At the time of discharge, the following lab data were noted;
Wbc=10200 (4.5 -10.8 × 109/L) ,Hgb=14.5 g/dl,plt=290,000,AST=135 u/l(10-42),ALT=37 u/l(7-45),Bilirubin µmol/lit (total=1.2,direct=0.3),cr=1.05 mg/dl
40 days after angioplasty, the patient returned complaining of icterus, itching and decreased appetite. The patient had no recent history of fever, abdominal pain, weight loss, nausea, vomiting, urine or stool discoloration or bleeding from any site in the body. He had no history of using OTCs, herbal remedies or alcoholic beverages. In the physical exam, the vital signs were stable and the patient did not appear ill or toxic. None of the stigmata of chronic liver disease were observed; the abdomen was soft and there was no sign of ascites or organomegaly. Cardiac and neurological examinations did not reveal any abnormalities.
A gastrointestinal consultation was requested for the patient and further tests were conducted as shown in table-1
Immunologic and serological tests for hepatitis A, B, C and E and tumor markers were negative (table 1); abdominopelvic ultrasound showed no lesions and subsequent MRCP displayed normal size and shape of the intrahepatic and extrahepatic biliary tracts as well as normal wall thickness and appearance of the gall bladder, without any lesions or filling defects. The pancreatic ducts were normal.
Based on the lack of anatomical lesions, a diagnosis of liver injury with a hepatocellular, cholestatic or mixed pattern due to autoimmunity or, more probably, drug-induced, was considered. Bearing in mind the patient’s most recent echocardiography, which had shown relatively improved cardiac function without the presence of clots in the left ventricle (EF=35%) , medications were discontinued based on their likelihood to cause liver damage, so statins were discontinued initially, followed by captopril and, lastly, warfarin. Despite these measures, no improvement in the lab findings or the patient’s jaundice was observed and there was actually an increase in the bilirubin level.
Bilirubin (total=13,direct =8.8),AST=130,ALT=250
After [witnessing] the rise in bilirubin, clopidogrel was substituted by ticegralor; subsequently, over the next two weeks, the patient’s jaundice improved and the lab results returned to normal.
Bilirubin (total=1.05,direct=0.7),AST=41,ALT=52,Alkaline Phosphatase=141
Medications other than clopidogrel were restarted gradually with 1 week intervals in between and over a follow-up period of two months, normalization of the lab data and his general condition was observed.