title: Azathioprine-induced hepatitis and cholestasis occurring 1 year after treatment.
abstract: Azathioprine is an immunosuppressive medication used in the management of many autoimmune conditions. Commonly reported adverse effects from azathioprine therapy are nausea and bone marrow suppression, while less common side effects include hepatotoxicity. We present the case of a 47-year-old man with a history of myasthenia gravis on azathioprine for 1 year, who presented to our institution with painless jaundice. On initial laboratory evaluation, the level of aspartate aminotransferase, alanine aminotransferase and total bilirubin were markedly elevated. Owing to the potential diagnosis of acute liver failure secondary to azathioprine toxicity, this medication was discontinued. A liver biopsy demonstrating drug-induced liver injury, along with high serum levels of 6-methylmercaptopurine nucleotide confirmed the diagnosis of azathioprine-induced hepatotoxicity. Upon discontinuation of the medication, the patient's transaminases and bilirubin levels improved steadily over the four-day hospital course. This case emphasises azathioprine's potential for hepatotoxicity, even 1 year after the initiation of its use.
authors.affiliation: Department of Medicine, University of Florida, Gainesville, Florida, USA.
authors.forename: Jason
authors.identifier: http://orcid.org/0000-0002-0572-5778
authors.initials: J
authors.lastname: Chertoff
authors.affiliation: Department of Medicine, University of Florida, Gainesville, Florida, USA.
authors.forename: Sabikha
authors.initials: S
authors.lastname: Alam
authors.affiliation: Department of Pathology, University of Florida, Gainesville, Florida, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Black
authors.affiliation: Department of Medicine, University of Florida, Gainesville, Florida, USA.
authors.forename: Islam Y
authors.initials: IY
authors.lastname: Elgendy
mesh_terms: D000284:Administration, Oral; D001379:Azathioprine / Q000009:adverse effects* / Q000627:therapeutic use; D001707:Biopsy, Needle; D056486:Chemical and Drug Induced Liver Injury / Q000209:etiology* / Q000473:pathology*; D002779:Cholestasis / Q000139:chemically induced / Q000473:pathology; D004305:Dose-Response Relationship, Drug; D005500:Follow-Up Studies; D006505:Hepatitis / Q000209:etiology / Q000473:pathology; D006801:Humans; D007150:Immunohistochemistry; D007166:Immunosuppressive Agents / Q000009:adverse effects* / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009157:Myasthenia Gravis / Q000175:diagnosis / Q000188:drug therapy*; D020127:Recovery of Function; D018570:Risk Assessment; D012720:Severity of Illness Index; D013997:Time Factors; D028761:Withholding Treatment
chemical_list: D007166:Immunosuppressive Agents; D001379:Azathioprine