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Specialist Department of Gastroenterology Türkiye
Yüksek Ihtisas Hospital
Sö
ütözü caddesi Atatepe
sitesi, B2 blok, 34/28 06510
Söütözü, Ankara, Turkey
fax 90 312 3124120
gskoklu{at}yahoo.com
Specialist Department of Gastroenterology Türkiye Yüksek Ihtisas Hospital
Research Fellow Department of Gastroenterology Türkiye Yüksek Ihtisas Hospital
Specialist Department of Gastroenterology Türkiye Yüksek Ihtisas Hospital
Instructor Department of Gastroenterology Türkiye Yüksek Ihtisas Hospital
Published Online, July 20, 2004. www.theannals.com, DOI 10.1345/aph.1E025
Case Report. About 13 months after the last cholestatic attack, the patient was referred to our department because of jaundice that had appeared 15 days earlier. He also produced dark urine; there was no history of fever or abdominal pain. He had been well clinically during the 13-month follow-up period. His recent history revealed that he had a dental abscess, for which he had been using cefuroxime axetile 500 mg twice daily for 10 days. He did not receive any other antibacterials when cefuroxime was discontinued, 7 days after which his symptoms had begun. Jaundice and dark urine gradually decreased and disappeared within 5 days after the first symptoms appeared. He denied taking any other medication or alcohol or using any herbal or folk remedies at any time.
Physical examination was normal except for mild icteric sclerae. Laboratory
findings were as follows: serum alkaline phosphatase (ALP) 646 U/L (normal
0–270), 
-glutamyl transferase 384 U/L (8–61), alanine
aminotransferase 427 U/L (0–41), aspartate aminotransferase 247
(0–38), total bilirubin 2.0 mg/dL (0–1.1), and direct bilirubin
0.7 mg/dL (0–0.3). Complete blood cell count, prothrombin time, and
other biochemical tests were within normal limits. Hepatobiliary
ultrasonography was also normal. He was followed in the outpatient clinic, and
liver function tests returned to normal other than a slight increase in ALP
level by 2 months after withdrawal of cefuroxime. Use of the Naranjo
probability scale indicated a probable relationship between cholestasis and
cefuroxime therapy in this
patient.2 He
was advised against future use of ß-lactam antibiotics.
Discussion. Cephalosporins along with penicillins are considered ß-lactam antibiotics. Cefuroxime is a second-generation cephalosporin that is widely used for respiratory and urinary infections. Although small rises in liver transaminases or alkaline phosphatases have been reported with all cephalosporins, at frequencies varying between <1% and up to 7%, and cholestasis has been reported with other cephalosporins as well, as of June 2004, no case of cholestatic jaundice secondary to cefuroxime has been described.3,4 Although uncommon, there may be a cross-sensitivity between cephalosporins and penicillins. It is not possible to determine the actual incidence of cross-reactivity between penicillins and cephalosporins, but evidence suggests the true rate is lower than usually appreciated.5 However, one report documented cross-reactivity in 5.4–16.5% of people.6 Nonetheless, cephalosporins can be given cautiously to patients with a history of delayed hypersensitivity to a penicillin.3 In our case, the cause of the liver injury due to both ampicillin and cefuroxime appears to be via a metabolic type of idiosyncratic toxicity. Clinicians should be aware of this adverse effect and cross-sensitivity regarding liver injury between ampicillin and cefuroxime.
References
K, Altiparmak E. Recurrent
cholestasis due to ampicillin. Ann Pharmacother 2003;37: 395-7.
DOI 10.1345/aph.1C273
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