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Hydralazine-Induced Autoimmune Hepatitis Precipitated by the Blood Transfusion.

To the Editor: Idiopathic drug-induced liver injury (DILI) affects 19 per 100,000 people per year. DILI is considered as one of the major causes of liver failure. Liver damage occurs because of direct toxicity or because of immunologic factors.1 Our aim is to present a case of hydralazineinduced autoimmune liver injury in a patient who had recently undergone a blood transfusion. A 70-year-old woman with a medical history of hypertension, diabetes mellitus, intellectual disability, anemia of chronic kidney disease, and end-stage renal disease who was scheduled for left arm arteriovenous fistula was referred to hospital for abnormal liver function tests (LFTs)—aspartate aminotransferase: 1203 U/ L, alanine aminotransferase: 2559 U/L, and alkaline phosphatase: 164 U/L. She received blood transfusion 3 weeks ago, without any documented transfusion reaction. The patient was asymptomatic, vitals were normal except elevated blood pressure 180/70 mm Hg. Laboratory results showed Hb: 8.7 gm/dL (at baseline) and creatinine was 4.72 mg/dL (at baseline). Urine toxicology screen was insignificant, blood acetaminophen level was 3 mg/mL, and blood alcohol level was less than 3 mg/dL. Ultrasound of the liver showed gall stones, echogenic liver, and no evidence of common bile duct dilation. Hepatitis viral panel was negative. She received N-acetylcysteine treatment for 3 days; LFTs did not improve and peaked on day 5 (Table 1). Complement levels, ceruloplasmin, and HIV immunoassay were negative. High antinuclear antibody (ANA) titer of 1:320 raised the possibility of autoimmune hepatitis. Anti-histone antibody was 1.5 (reference ,0.9 U). The rest of the autoimmune panel was negative (Table 2). Further history revealed that the patient was taking hydralazine for few years. Hydralazine was discontinued, and prednisone was started. LFTs trended down significantly in 1 week (Table 1). The patient was discharged on prednisone taper over 6 weeks; follow-up laboratory results after 6 weeks and 6 months showed normalized LFTs. Autoimmune-like drug-induced liver injury (DIAIH) is a subtype of DILI which is hard to differentiate from idiopathic autoimmune hepatitis (iAIH). DI-AIH usually presents 6 months after the start of medication.1,2 Common drugs that cause autoimmune liver injury are methyldopa, minocycline, nitrofurantoin, and hydralazine.1 In hydralazine-induced hepatitis, liver damage is variable; it may present as hypersensitivity reaction,