%0 Journal Article
%T Tocilizumab-Induced Acute Liver Injury in Adult Onset Still¡¯s Disease
%A Michael Drepper
%A Laura Rubbia-Brandt
%A Laurent Spahr
%J Case Reports in Hepatology
%D 2013
%I Hindawi Publishing Corporation
%R 10.1155/2013/964828
%X Background. Tocilizumab, a monoclonal humanized anti-IL-6 receptor antibody, is used in treatment of refractory adult onset Still¡¯s disease (AOSD). Mild to moderate liver enzyme elevation is a well-known side effect, but severe liver injury has only been reported in 3 cases in the literature. Case. A young female suffering from corticoid and methotrexate refractory AOSD was treated by tocilizumab. After 19 months of consecutive treatment, she developed acute severe liver injury. Liver biopsy showed extensive hepatocellular necrosis with ballooned hepatocytes, highly suggestive of drug-induced liver injury. No other relevant drug exposure beside tocilizumab was recorded. She recovered totally after treatment discontinuation and an initial 3-day course of intravenous N-acetylcysteine with normalization of liver function tests after 6 weeks. Conclusion. Acute severe hepatitis can be associated with tocilizumab as documented in this case. Careful monitoring of liver function tests is warranted during tocilizumab treatment. 1. Introduction Adult onset Still¡¯s disease (AOSD) is a systemic inflammatory disease clinically characterized by remittent fever, polyarthritis, stain rash, and lymphadenopathy in association with deregulated proinflammatory cytokines (interleukin-1, -6 and -18, tumor necrosis factor ¦Á, and interferon ¦Ã) production [1, 2]. Of interest, a correlation of IL-6 serum levels with AOSD¡¯s activity has been described [1, 3]. Tocilizumab is a neutralizing humanized monoclonal antibody against the human interleukin-6 (IL-6) receptor that is able to block soluble and membrane-bound receptors [4]. It is licensed over the world as second-line treatment for rheumatoid arthritis (RA) and in Japan and Europe for juvenile idiopathic arthritis [5, 6]. Disease improvement or remission has been reported following tocilizumab treatment in refractory AOSD [2, 7]. 2. Case Report An 18-year-old female from Angola was diagnosed with AOSD in September 2010 following recurrent fever, polyarthritis, abdominal lymphadenopathy, liver and spleen enlargement, and hyperferritinemia. She was initially treated with oral corticoids with early methotrexate adjunction due to incomplete control of symptoms. Despite this treatment, corticoids could not be tapered under the dose of 15£¿mg/day, motivating introduction of tocilizumab (8£¿mg/kg) in June 2011, permitting interruption of corticoids and methotrexate in December 2011. In 2012, she had no symptoms and liver function tests were normal under tocilizumab once every 3 weeks. On January 21, 2013, she complained of nausea,
%U http://www.hindawi.com/journals/crihep/2013/964828/