A rare case of recurrent prolonged hepatotoxicity due to ornidazole.

Ornidazole is generally well tolerated antibiotic which is synthetic derivative of nitroimidazole. Serious side effects are very rarely encountered. The most common side effects are metallic taste, nausea, vomiting, abdominal pain and diarrhea.1 Even though it has been presented that ornidazole has side effects (for example neurotoxicity, glossitis and stomatitis). Hepatotoxicity related to this drug has been rarely reported. Before, this phenomenon was described with the three cases by Tabak, et al.2 Herein, we presented a case of recurrent prolonged hepatotoxicity associated with ornidazole. A 45-years-old female patient was admitted to our outpatient clinic with nausea, vomiting, loss of appetite, jaundice and abdominal pain. Her past medical history revealed vaginitis treated with two days course of oral ornidazole 500 mg twice daily. She also mentioned about ornidazole associated hepatitis following use of the drug a year ago. Meanwhile, elevated liver enzymes after ornidazole treatment in that period were as follows: ALT 720 U/l, AST 690 U/l, alkaline phosphatase 161 U/l, GGT 102 U/l, total bilirubin 8.2 mg/dl, direct bilirubin 4.0 mg/dl. On admission, physical examination revealed scleral jaundice and tenderness in the right upper quadrant. Laboratory examination revealed the following: ALT 397 U/l, AST 333 U/l, GGT 68, total bilirubin 1, 94 mg/dl. Alkaline phosphatase, albumin and prothrombin time were normal. She did not consume alcohol. She did not take herbal products and concomitant medication. She had not travelled any region of the world. Laboratory tests were normal for autoimmune hepatitis, thyroid tests, haemochromatosis or Wilson's disease. Viral markers for A-E were negative. Antinuclear antibody was negative. Hepatobiliary ultrasound revealed no evidence of extrahepatic obstruction, biliary ductal disease, hepatic parenchymal abnormalities, or cholelithiasis. These findings suggested hepatocellular type liver injury related with ornidazole. After ceasing the drug, transaminase and bilirubin levels returned to normal range after two months. We didn’t perform percutaneous liver biopsy because of liver function tests decreased to normal range and the patient didn’t accept. Besides she had a history of ornidazole induced hepatotoxicity. Ornidazole induced liver injury may be cytolytic, cholestatic, and/or mixed. In this report, we described a patient recurrent hepatitis due to ornidazole. Interestingly, hepatotoxicity due to ornidazole was appeared early as compared with previous cases.3 In conclusion, ornidazole which is frequently used nitroimidazole derivative may cause recurrent hepatitis. Physicians and patients should be awareness of hepatotoxicity due to ornidazole. Early recognition and withdrawal of the drug may prevent further damage.