P1052 - Drug-Induced Liver Injury After Initial Therapy With TMP-SMZ in AIDS Patient: A Case Report

Beatriz Torre, MD¹, Rebecca Loh, MD², Dina Halegoua-DeMarzio, MD^2
1Thomas Jefferson University, Philadelphia, PA; ²Thomas Jefferson University Hospital, Philadelphia, PA

Introduction: Drug-induced liver injury (DILI) is a potentially fatal cause of liver disease. Pre-existing liver disease, genetic susceptibility and concomitant hepatitis B or C or HIV may predispose certain individuals to poor outcomes. We describe a case of trimethoprim/sulfamethoxazole (TMP-SMZ) DILI in a patient co-infected with AIDS and hepatitis B.

Case Description/Methods: A 53 year-old male with untreated HIV presented to a local hospital with one week of dizziness, syncope and right-sided weakness. He was diagnosed with cerebral toxoplasmosis and started on IV TMP-SMZ on hospital day 14 with initial improvement in mental status. His hospitalization was complicated by acute renal failure with worsening mental status and newly elevated liver function tests (LFTs) from normal at baseline.






LFTs on hospital day 25 were notable for TBili 0.9, Dbili 0.5, INR 0.96, AlkP 104, AST 121, ALT 407 (Table 1). That day, Bactrim was discontinued and IV NAC was initiated on day 27. Liver biopsy revealed “cholestatic hepatitis with pericentral hepatocellular and canalicular cholestasis, mild lobular and portal inflammation consistent with drug induced liver injury”. Subsequent hospital course was complicated by E. Coli bacteremia and progressive renal and liver injury (Figure 1). The patient unfortunately passed away from multiorgan failure on hospital day 42.

Discussion: TMP-SMZ is a fixed antibiotic combination used for bacterial infections and as prophylaxis against opportunistic infections in HIV patients. Although generally well-tolerated, TMP-SMZ can have a higher rate of adverse reactions in HIV-positive patients: 40–80% of HIV infected individuals, compared to 3–5% in the general population. These drug reactions range from hypersensitivity-like reactions to organ failure.




AIDS has been suggested to be significantly associated with the development of hepatotoxicity. The pathogenesis is unknown, but may reflect disease-induced alterations in bioactivation or detoxification of reactive metabolites, as well as immune dysregulation. Although typical prognosis for TMP-SMZ-associated DILI is favorable with expected recovery in 2-8 weeks, prognosis is markedly worse in AIDS patients as well as patient’s co-infected with HBV or HCV. There are currently no guidelines for monitoring high risk patients for DILI in the hospital setting. In our case, we incidentally discovered his DILI after eleven days of treatment with TMP-SMZ. Moving forward, we should consider screening parameters in these higher risk populations.




Disclosures:


Beatriz Torre, MD¹, Rebecca Loh, MD², Dina Halegoua-DeMarzio, MD². P1052 - Drug-Induced Liver Injury After Initial Therapy With TMP-SMZ in AIDS Patient: A Case Report, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.