Associate Chief Metropolitan Hospital New York, New York, United States
Case Diagnosis: 52 year-old man with Mycobacterium avium-intracellulare infection s/p cervical cord decompression
Case Description: 52-year-old male history of CAD, STEMI, HTN, HFrEF, DM2, MAC on RIPE (rifampin, isoniazid, pyrazinamide, and erythromycin) + azithromycin therapy, cervical cord compression with myelopathy, and cervical and lumbar spondylosis presented to an outside hospital for C4/C5 ACDF, C6 corpectomy, C4-7 anterior cervical decompression, instrumented fusion. After uncomplicated course, patient was admitted to acute inpatient rehabilitation (AIR) on post-operative day 8 for impaired mobility. On admission to AIR, strength was 5/5 on the right side, 4-5/5 in LUE, and ⅕ in LLE secondary to lower back pain. Light touch sensation, proprioception, and reflexes were intact. Screening tests upon admission to our AIR include: CMP, CBC, magnesium, phosphorus, b/l lower extremity ultrasound, CXR. The patient was found to have transaminitis (ALT/AST/ALP 271/157/150) on AIR Day 1 (AIRD1). Repeat LFTs showed 184/171/146 on AIRD4.
Discussions: In spite of ALT/ALP decreasing, as LFTs remained high, we decided to stop RIPE+azithromycin; acetaminophen PRN, and statin also discontinued. LFTs continued to rise for few days before normalizing: AIRD5 281/365/160, AIRD6 281/518/159, AIRD7 256/315/159, AIRD8 223/169/148, AIRD10 123/52/140. CBC showed reactive thrombocytosis with initial value of 501 increased to 834 AIRD5, 629 AIRD11. Patient’s back pain alleviated, strength improved to 5/5 throughout AIR stay. Discharged AIRD11 walking independently. Isoniazid is second only to acetaminophen as a drug that can cause acute hepatic failure. Monitoring LFTs is essential for patients on RIPE. In this case, this reaction may have worsened without detection for an extended period.
Conclusions: AIR screening labs helped alert the team to possible liver damage, underscoring the importance and utility of admissions screening and subsequent monitoring based on initial evaluation.
