Recurrent cholestasis by amoxicillin-clavulanic acid: the importance of a correct diagnosis of hepatotoxicity.

We present the case of a 62-years-old male, diabetic, in treatment with metformin, who was hospitalized because of jaundice and itching. He presented symptoms of jaundice the previous year. It was performed a cholangioRNM, a study of autoimmunity and hepatitis serology, but all these studies were normal. However, a hepatic hydatid cyst was detected and surgically operated. The patient had taken AC some days before. The jaundice vanished after 4 months. He was hospitalized for jaundice and itching with two weeks of evolution. He showed neither fever nor abdominal pain. He has been taken AC for the last 20 days. The physical examination revealed jaundice with normal cardiopulmonary and abdominal exploration. The additional tests showed: normal hemogram and coagulation, total bilirubin 12 mg/dl (0-1.1) at the expense of the direct bilirubin, alkaline phosphatase 107 U/L (40129), gammaglutamyl transpeptidase, 161 U/L (9-48), normal GOT and GPT, as well as tumor markers and proteinogram. Although the first suspicion was the toxic hepatitis, it was made a wide differential diagnosis. An abdominal ultrasound and a magnetic cholangioRNM were requested and showed: sequelae of the hydatid cyst surgery and abnormalities suggesting the existence of diffuse inflammatory changes in the hepatic parenchyma. The vesicle, bile ducts and pancreas were normal. In addition, it was carried out a wide study to exclude other causes, including immunity study (ANA, anti-KLM, anti smooth muscle antibody, AMA) which was negative. Negatives viral serology (VHA, VHC, VHB, VEB, VIH, CMV). Serum alfa-1 antitrypsin, ferritin and ceruloplasmin were also normal. During hospitalization, the pruritus persisted and total bilirubin increased up to 25 mg/dl. Considering the negative results and the anxiety of the patient, a hepatic biopsy was performed that was informed as morphologic changes supporting cholestasis. The patient was discharged home with the following diagnosis: Toxic hepatitis by AC. Two months later, the patient was asymptomatic and serum bilirubin, transaminases and alkaline phosphatase were normal.