A 52-year-old woman presented feeling giddy and generally unwell. She complained of episodic upper abdominal pain and headaches.
The patient had a past history of pulmonary embolism and was taking warfarin. She was also taking phenytoin to prevent seizures and long-term amoxycillin for cerebral abscesses. This infection had been slow to resolve so 36 hours before her presentation, clindamycin 450 mg three times daily had been added to her treatment.
Physical examination was unremarkable and her warfarin and phenytoin concentrations were in the therapeutic range. The woman's liver function had been normal before starting clindamycin but was now abnormal:
- alanine aminotransferase 340 U/L (normal range 5–40 U/L)
- aspartate aminotransferase 855 U/L (normal range 5–40 U/L)
- gamma-glutamyl transferase 524 U/L (normal range 12–43 U/L)
- alkaline phosphatase 159 U/L (normal range 30–150 U/L)
- lactate dehydrogenase 714 U/L (normal range 100–230 U/L).
The patient's bilirubin, albumin and alpha-fetoprotein concentrations were normal. Serology for hepatitis B and hepatitis C infection was negative. Apart from a previous cholecystectomy, the liver and biliary tree were normal on a CT scan.
Clindamycin was ceased, but no other changes were made to her drugs. Three days after stopping clindamycin, her symptoms had resolved and her liver function tests were almost back to baseline values.
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