Background

Amoxicillin-clavulanate can cause both liver injury and acute kidney injury. The majority of the existing literature has described liver-related injury, with fewer reports noting kidney injury. In this report, we describe a rare case of concomitant drug-induced liver injury and acute interstitial nephritis as a result of amoxicillin-clavulanate exposure.

Case Presentation

A 62-year-old male presented to the emergency department with weight loss, nausea, and diarrhea. Two weeks prior to presentation, he was treated for sinusitis with a ten-day course of amoxicillin-clavulanate (875 mg-125 mg) twice daily. The patient was jaundiced, and his abdominal examination revealed mild distension. Labs included a blood urea nitrogen of 98, creatinine of 6.6 mg/dL, total bilirubin of 20.5, alkaline phosphatase of 397, aspartate transaminase of 138, alanine transaminase of 88, and International Normalized Ratio of 11.4 with pro-time of 127.9. A complete blood count was notable for 9.5% eosinophils, with a total level of 700 eosinophils. A computerized tomography scan of the abdomen was performed, which revealed gallbladder wall thickening; subsequent right upper quadrant ultrasonography showed a minimally distended gallbladder and focally dilated intrahepatic ducts in the left lobe of the liver. Given concern for renal failure, the patient was admitted to the ICU. He was started on high-dose methylprednisolone for empiric treatment of suspected autoimmune hepatitis. Given that drug-induced liver injury was on the differential, tissue biopsies were obtained. A percutaneous core kidney biopsy revealed acute tubular injury with bile cast nephropathy, focal acute tubulointerstitial nephritis, moderate arteriolar hyalinosis, and mild arteriosclerosis. The liver biopsy showed bile pigment within hepatocytes and bile canaliculi in peri-central vein areas. These biopsy findings were suggestive of amoxicillin-induced renal and hepatic injury. The patient was continued on high-dose IV steroids (which he received for a total of five days) that were transitioned to an eighteen-day oral prednisone taper. His creatinine gradually normalized, and the patient’s LFTs remained mildly elevated on the day of discharge.

Discussion

This case study demonstrates a rare occurrence in which a patient developed drug-induced liver injury and renal failure. Though antibiotics are widely used to treat infection, their use is not without consequences. In our case, the pathology revealed findings consistent with the immuno-allergic response in amoxicillin-clavulanate drug-induced injury. As this relays the etiology behind the multiorgan failure, tissue biopsy is an essential component in guiding the treatment of patients afflicted with concomitant hepatic failure and renal failure caused by amoxicillin-clavulanate.