Thread by @ebtapper

A patient with diabetes and recent NSTEMI treated with stent, clopidogrel, and atorvastatin ~2 months ago is transferred from OSH with ALT 1500, bilirubin 15

The leading diagnosis is statin liver injury

But that's not what it is.

Not at all
🧵
#livertwitter #liverstory

When she went to OSH, a bunch of tests were ordered

Blood tests (HCV ab, HAV, HBV surface antigen and core IgM, ANA, ASMA, IgG...) - all negative

Imaging (ultrasound, MRI) - nothing, no stones

OSH: It had to be the statin!

Narrator: But it wasn't

Statin induced liver injury is super rare. Consider it but dont close your mind to other possibilities.

If you want rates of injury, just ask @bjornsson_s who studied the Swedish national register in this @JHepatology paper. sciencedirect.com/science/articl…

When ALT is ⬆️⬆️, few things that can do it (

https://twitter.com/ebtapper/status/1031555677095948289?s=20&t=eyDQ6i5ZpD_pGnPWA75sRw

)
Top
1: Ischemic hepatitis, often happens in ❤️ failure. Not her tho
2: Bile duct stones. Unlikely with persistent high ALT & normal MRI
3: Drugs (e.g tylenol)
4: Viruses

Maybe it IS the statin!?
But it's not

So we repeated some tests. But we got some fancy antibodies (LKM, SLA), urine copper, PCRs for Hep B, Hep C, and through in Hep D.

And we held the clopidogrel to prepare for liver biopsy.

But we didnt need to do it

We asked about supplements, injection drugs, cocaine use, travel, sexual history, blood transfusions. Every answer was the same: no.

We asked twice. We needed to know about exposures, risk factors, especially for hepatitis C.

Why? Because the PCR came back.

She had acute hep C

Most hepatitis C is asymptomatic at first but 10-15% becomes acutely symptomatic. The antibody may not be detected early on. Need PCR
Figures 1-2: Lancet 2008;372:321–32

This used to be rare but has become more common of late (Figure 3, PMID: 32271725)

About 1 in 4 cases of acute hep C resolve spontaneously (PMID: 23908124).

We used to wait & see by 6-12 months without treating because treatment was interferon (horrible). But now with the direct antivirals, we often treat earlier (PMID: 29059461)

But this was a long time ago

So how did this happen?

How did she get infected with hepatitis C?

There was one risk factor we didnt consider

Fortunately we reported the infection to the department of public health

It turned out that this was unfolding the context of the largest outbreak of healthcare-associated hepatitis C transmission in US history

45 patients got infected by hepatitis in cardiac cath labs across the US all connected by the same technician (ncbi.nlm.nih.gov/pmc/articles/P…)

Drug diversion was the cause

A healthcare provider takes the drug (fentanyl) intended for patient care (sedation for cardiac cath) and replaces the syringe with saline but tainted with blood.

So what happened to my patient?

They made a full recovery. Normal bilirubin.
But the hep C became chronic.
Within a couple of years, highly effective pills for hepatitis C would become available.
She is now cured
What happened to the person who infected her?
They are in prison

In summary:

1⃣⬆️⬆️ALT has a limited differential (Ischemia, stones, drugs, viruses are most common)
2⃣Check viral PCR when evaluating acute infections
3⃣Report acute viral hep to public health. Think about drug diversion when you pick up HBV/HCV
4⃣Statin liver injury is rare

Thank you for reading this #liverstory. I hope you enjoyed. As always, some facts are changed to protect identities.