A case of indometacin-induced acute hepatitis developing into chronic autoimmune hepatitis

This Case Study describes a 47-year-old woman who was treated with indomethacin for osteoarthritis-related hip pain. Soon after beginning treatment she developed nausea, vomiting, abdominal pain, dark urine and jaundice. Despite discontinuing all medications, her symptoms worsened. Treatment with prednisone 40 mg/day was initially successful, but after tapering (over 18 months) and then discontinuing prednisone her liver chemistry test results worsened and a liver biopsy showed evidence of chronic hepatitis. Background A 47-year-old woman who presented with hip pain as a result of osteoarthritis was treated with indometacin. Ten days after beginning treatment she developed jaundice and ascites. All medications were discontinued, but her symptoms continued to worsen. Investigations Physical examination, laboratory tests and radiologic examinations, including liver chemistry tests, viral serologies, serum iron studies, ceruloplasmin and alpha-fetoprotein analyses, autoimmune serologies, ascites studies, abdominal CT, liver ultrasound and liver biopsy. Diagnosis Severe biopsy-proven hepatitis that progressed to chronic autoimmune hepatitis. Management Treatment with prednisone 40 mg/day was initially successful. The dose of the therapy was tapered over 18 months and then discontinued, after which time the patient's liver chemistry test results worsened. Repeat liver biopsy samples showed evidence of chronic hepatitis, and her liver chemistry test results improved when prednisone was restarted. The patient was maintained on 750 mg twice-daily mycophenolate mofetil and prednisone was decreased to 5 mg every other day.