Gastroenterologists have been reminded that the widely-used anti-acne drug minocycline may be a cause of otherwise unexplained liver injury in young people.
Although hepatotoxicity is a rare side effect of the tetracycline drug, its widespread use in the treatment of acne vulgaris in adolescents means it is the single most commonly implicated antimicrobial in drug-induced liver injury children, according to clinicians for the Department of Gastroenterology at the Royal Children’s Hospital in Melbourne.
They report a case of unexplained liver injury in which a 15-year old girl underwent extensive investigations for possible causes – including having a liver biopsy – before a diagnosis of exclusion was made based on her use of minocycline for four weeks as treatment for acne.
The girl presented with an 8-day history of fever, rash and abdominal pain. She was anicteric with cervical and axillary lymphadenopathy but had no peripheral oedema or stigmata of chronic liver disease. Abdominal examination revealed tender hepatomegaly with a palpable left lobe and an enlarged spleen. There was some free fluid as evidenced by bilateral flank dullness.
Blood investigations revealed mild normocytic anaemia with neutropenia, reactive lymphocytosis, eosinophilia and thrombocytopenia. Liver function tests (LFT) showed a predominant ‘hepatitis’ picture with normal conjugated bilirubin and low Albumin. An ultrasound of the abdomen revealed mild hepatomegaly, significant splenomegaly, intra-abdominal lymphadenopathy and mild-to-moderate ascites. Acute viral hepatitis, bacteraemia or meningococcal sepsis, autoimmune hepatitis (AIH), haemophagocytic lymphohistiocytosis and Wilson’s disease, were among the possible causes considered by the treating clinicians.
In view of worsening her worsening LFTs, a liver biopsy was performed that was suggestive of acute portal and lobular hepatitis with lymphocytic and abundant eosinophilic infiltrate. No features suggestive of chronic liver disease or AIH were evident.
Once the diagnosis of drug-induced hypersensitivity was established on liver and skin biopsy, the girl was started on IV steroids and discharged home on tapering doses of oral steroids. She was clinically well when followed up after six months.
The authors of the report, published in the Journal of Paediatrics and Child Health, say it highlights the role of tetracyclines in drug-induced injury, which accounts for 20% of paediatric acute liver failure.
And while the overall incidence of hepatotoxicity with minocycline is rare – about 1/10 000 exposed person-months – the case report is a reminder of the importance of a detailed drug history when faced with a patient with liver dysfunction
“A careful drug history should be obtained in every child with deranged LFT, including use of prescription, over-the-counter, herbal and alternative medications for up to 6 months prior to the onset of liver dysfunction,” they conclude.