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Successful Treatment of Fosinopril-Induced Severe Cholestatic Jaundice with Plasma Exchange

Clinical Specialist, Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan

Cheng-Ju Yu, MD

Clinical Specialist, Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospitale

Po-Heng Chuang, MD

Clinical Specialist, Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital

Hsueh-Chou Lai, MD

Clinical Specialist, Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital

Chang-Hu Hsu, MD

Clinical Specialist, Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital

Ken-Sheng Cheng, MD

Clinical Specialist, Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital

Cheng-Yuan Peng, MD PhD

Director, Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital

I-Ping Chiang, MD

Clinical Specialist, Department of Pathology, China Medical University Hospital

Reprints: Dr. Hsueh-Chou Lai, Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, No. 2, Yuh-Der Rd., North District, Taichung 40447, Taiwan, fax 886-4-22023119, codecol{at}yahoo.com.tw

OBJECTIVE: To describe a case of fosinopril-induced severe cholestatic jaundice successfully treated with plasma exchange.

CASE SUMMARY: A 78-year-old Taiwanese male presented with yellowish skin and generalized itching one month after starting fosinopril 10 mg once a day. Other drugs taken by the patient were excluded as the probable cause of jaundice. Diagnostic modalities, including abdominal ultrasound, computed tomography, and endoscopic retrograde cholangiopancreatography, revealed no evidence of biliary tract obstruction or intraabdominal tumor. According to the Council for International Organizations of Medical Science (CIOMS) scale, fosinopril was a highly probable cause of the patient's jaundice. Liver biopsy showed cholestasis without bile duct damage. Based on results of the CIOMS scale assessment and pathological characteristics of the liver, the diagnosis was highly probable that fosinopril had induced cholestatic jaundice in our patient. During hospitalization, the patient developed severe jaundice and liver failure, despite conservative treatment and withdrawal of fosinopril. He underwent a 5-day course of plasma exchange therapy, and the serum bilirubin level declined rapidly after treatment. His liver function returned to normal 2 months after treatment.

DISCUSSION: Angiotensin-converting enzyme (ACE) inhibitor-induced hepatotoxicity is rare and only a few cases, with most involving captopril, have been reported in the English-language literature. Hepatotoxicity caused by fosinopril is extremely rare. Most ACE inhibitor-induced hepatotoxicity is mild and transient, but it can be fatal. Although orthotopic liver transplantation (OLT) is the standard method for treating drug-induced liver failure, plasma exchange therapy is an alternative therapeutic method or a bridge to OLT for treating liver failure.

CONCLUSIONS: Plasma exchange therapy may play a valuable role in the treatment of fosinopril-induced cholestatic jaundice and liver failure. This intervention can be considered for temporary liver support until recovery or OLT.

Key Words: angiotensin-converting enzyme inhibitor, cholestatic jaundice, hepatotoxicity, liver failure, plasma exchange therapy

Published Online, November 18, 2008. www.theannals.com, DOI 10.1345/aph.1L229