Acute non-autoimmune hepatitis induced by alemtuzumab: a case report

Address for correspondence: Vanessa Lauanna Lima Silva (email: [e-mail]).

Abstract

Case Presentation: A 37-year-old female patient with highly-active relapsing-remitting multiple sclerosis (RRMS) was admitted for alemtuzumab treatment. The formal protocol of 12 mg for 5 days with 1 g of methylprednisolone daily for the first 3 days plus concomitantly acyclovir, diphenhydramine, and acetaminophen (< 4 g a day) was performed. On the third day of infusion, an unexpected rise in her liver function tests was detected. The basal ALT raised from 20 U/L to 1441 U/L on day 3, with an AST of 522 U/L, ALP of 119 U/L, GGT of 433 U/L, and bilirubin of 0.5 mg/dL. There were no signs of acute liver failure, such as encephalopathy, coagulopathy, hepatomegaly or hepatorenal syndrome. Serologies were negative (hepatitis A, B, and C antibodies, cytomegalovirus, and Ebstein-Barr virus IgM). Antinuclear, antimitochondrial, anti-LKM1, and anti-smooth muscle antibodies were negative. The Gastroenterology team was consulted, and a drug-induced liver injury (DILI) associated with alemtuzumab was suspected. The Roussel Uclaf Causality Assessment Method (RUCAM) score was of 6, making DILI “probable”. Alemtuzumab was definitely interrupted on the fourth day of treatment, coinciding with a drop in ALT from 440 U/L on day 8. Nowadays, the patient is under regular treatment with rituximab.

Discussion: Alemtuzumab is a monoclonal antibody to human CD52 on lymphocytes. It is a highly-effective therapy for RRMS treatment. Alemtuzumab is related with some adverse events, including opportunistic infections and autoimmunity. Thyroid disorders, immune thrombocytopenic purpura, nephropathies, and autoimmune hepatitis have been described. Despite previously-reported autoimmune hepatitis, DILI is an unexpected adverse effect of this medication.

Final Comments: We herein report a case of acute non-autoimmune hepatitis induced by alemtuzumab in a patient with RRMS during the first round of treatment. To our knowledge, the present is the second published report on DILI associated with alemtuzumab, which highlights the scientific relevance of the present case report.

 

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Publikationsverlauf

Artikel online veröffentlicht:
02. Oktober 2024