A Challenge for Diagnosing Acute Liver Injury with Concomitant/Sequential Exposure to Multiple Drugs: Can Causality Assessment Scales Be Utilized to Identify the Offending Drug?

Table 1

Correlation between clinical and biochemical manifestations and drug administration.

Time from onset of illness	Signs/symptoms	Drug exposure	Laboratory values
			ALT	ALP	Total bilirubin	Direct bilirubin	Misc.
−5	Sore throat	Amoxicillin started
0	Fever, anorexia, dysphagia, neck swelling, and cervical lymphadenopathy	Ceftriaxone and vancomycin started
3–5	Worsening of neck swelling	Ceftriaxone and vancomycin discontinued, and ampicillin/sulbactam and steroid started
5–10	Diarrhea	Ampicillin/sulbactam and steroid discontinued, and clindamycin and probiotics started
10	Fever, headache, dizziness, chest pain on coughing, and dark urine. Hepatosplenomegaly, RUQ tenderness	Clindamycin switched to ampicillin/sulbactam	406	404	3.0	2.7
16–23	Generalized maculopapular rash and pruritus	Ampicillin/sulbactam	152	737	8.8
25–30	Abdominal pain, vomiting. Hepatomegaly	Ampicillin/sulbactam	124	780	9.9		AST 130
48	Chest pain, fatigue, pruritus, acholic stools, and jaundice		138	713	13.4	8.8	Cholesterol 1044, GGT 347,
53	Increasing pruritus, anorexia		117	651	12.7	8.5	GGT 294
67	Anorexia, pruritus		48	493	12.6	8.7	GGT 77
83	Anorexia		83	497	8.3	5.5	GGT 273
111	No anorexia		51	670	2.3	1.2	GGT 507

Time is in days. ALP = alkaline phosphatase, units used for ALT, ALP, and GGT used are IU. Bilirubin and cholesterol are displayed in mg/dL. Misc. = miscellaneous lab values.