Concomitant Drug Reaction with Eosinophilia and Systemic Symptom Syndrome from Ethambutol and Autoimmune Hepatitis from Isoniazid

Joon Hyuk Choi; Nae-Yun Heo; Seung Ha Park; Chan Sun Park; Kyeong Min Jo; Woo Gyeong Kim; Kyung Han Nam

doi:10.4166/kjg.2016.67.5.267

Journal List > Korean J Gastroenterol > v.67(5) > 1007511

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Choi, Heo, Park, Park, Jo, Kim, and Nam: Concomitant Drug Reaction with Eosinophilia and Systemic Symptom Syndrome from Ethambutol and Autoimmune Hepatitis from Isoniazid

Case Report

Korean J Gastroenterol 2016;67(5):267-271.

Published online: 4 October 2016

DOI: https://doi.org/10.4166/kjg.2016.67.5.267

Concomitant Drug Reaction with Eosinophilia and Systemic Symptom Syndrome from Ethambutol and Autoimmune Hepatitis from Isoniazid

Joon Hyuk Choi, Nae-Yun Heo, Seung Ha Park, Chan Sun Park, Kyeong Min Jo, Woo Gyeong Kim¹, Kyung Han Nam¹

Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea

¹Department of Pathology, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea

Correspondence to: Nae-Yun Heo, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, 875 Haeun-daero, Haeundae-gu, Busan 48108, Korea. Tel: +82-51-797-0661, Fax: +82-51-797-0941, E-mail: nyheo@hanmail.net

Received 15 January 2016 Revised 11 March 2016 Accepted 13 March 2016

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Antituberculosis drugs can produce levels of hepatotoxicity ranging from mild elevation of aminotransferase to severe acute hepatitis. A few cases of drug-induced autoimmune hepatitis or the drug reaction with eosinophilia and systemic symptom (DRESS) syndrome by anti-tuberculosis medications have been reported. However, concomitant occurrence of these two disorders has not been reported. Here, we present a case of severe acute hepatitis with DRESS syndrome and autoimmune hepatitis resulting from primary standard anti-tuberculosis drugs. Both conditions were successfully treated with a systemic steroid regimen.

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Keywords: Drug hypersensitivity syndrome, Hepatitis, autoimmune, Antitubercular agents

References

1. Tostmann A, Boeree MJ, Aarnoutse RE, de Lange WC, van der Ven AJ, Dekhuijzen R. Antituberculosis drug-induced hepatotoxicity: concise uptodate review. J Gastroenterol Hepatol. 2008; 23:192–202.

2. Lee JH, Park HK, Heo J, et al. Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome induced by celecoxib and anti-tuberculosis drugs. J Korean Med Sci. 2008; 23:521–525.

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4. Kardaun SH, Sidoroff A, Valeyrie-Allanore L, et al. Variability in the clinical pattern of cutaneous side-effects of drugs with systemic symptoms: does a DRESS syndrome really exist? Br J Dermatol. 2007; 156:609–611.

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8. Kim JY, Sohn KH, Song WJ, Kang HR. A case of drug reaction with eosinophilia and systemic symptoms induced by ethambutol with early features resembling Stevens-Johnson syndrome. Acta Derm Venereol. 2013; 93:753–754.

9. Lens S, Crespo G, Carrión JA, Miquel R, Navasa M. Severe acute hepatitis in the DRESS syndrome: Report of two cases. Ann Hepatol. 2010; 9:198–201.

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Fig. 1.

The patient developed an erythematous facial edema (A) and generalized maculopapular skin rash (B).

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Fig. 2.

Liver biopsy showed interface hepatitis (red arrows) (H&E, ×100; A), and lympho-dominant infiltration with eosinophil (blue arrows) and plasma cell (green arrow) in portal tract (H&E, ×200; B). (C) Some lobular hepatocytes showed the rosette formation (blue arrows) (H&E, ×200).

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Fig. 3.

The treatment flow during the desensitization for the primary anti-tuberculosis drugs. INH, isoniazid; ETB, ethambutol; RIF, rifampin; PZA, pyrazinamide; Lfx, levofloxacin; Cs, cycloserine; Pto, prothionamide; Pd, prednisolone.

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Fig. 4.

The level of alanine aminotransferase according to the anti-tuberculosis medications and prednisolone administration. Lfx, levofloxacin; Cs, cycloserine; Pto, prothionamide; INH, isoniazid; ETB, ethambutol; RIF, rifampin; PZA, pyrazinamide; HERZ, isoniazid, ethambutol, rifiampin, pyrazinamide; Pd, prednisolone.

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