Drug-induced hepatitis?

[codiver]

I am a 37 yo female, active, and fit who underwent transcatheter PFO closure.  I was prescribed 75mg Plavix daily + 325mg Aspirin afterward.  After 2 days on Plavix, I became extremely nauseous.  I would become nauseous each time I took it at bedtime and often this would continue the following morning.  Within two weeks, I had joint paint, nausea, fatigue, nosebleeds, bruising, and petechial rash.  I took 165mg 80% silymarin for 14 days and this helped.  5 days after stopping silymarin, my symptoms returned in full.  I then had a midnight attack of acute RUQ pain with nausea/vomiting that landed me in the ER.  My ALT was 193, AST 183, mildly elevated bilirubin, platelets 172K, neutrophils 94%.  Ultrasound  found no stones or sludge, but my CBD was 7mm and the intrahepatic duct was mildly dilated.  My PCP did labs 48 hrs later and ordered HIDA scan.  Results were ALT 470, AST 100, scan ejection fraction 25%, viral panels & autoimmune panels negative.  I stopped Plavix - 3 days later ALT 124, AST 21.  Before Plavix ALT 14, AST 18, platelets 281K.  PCP dx is drug-induced hepatitis due to Plavix.  While I agree Plavix caused me problems, my RUQ episode was textbook biliary colic.  4 years ago after pregnancy I had a week of clay-colored stools and RUQ pain after eating potato chips.  No labs were done and US found no stones.  I avoided fatty foods for years and had no other problems until now.  I also had one recent episode 8 weeks ago involving taking IB & APAP over  5 days for sore throat where I got bruising, fatigue, frequent urination, and muscle weakness.  My PCP's plan is to watch labs another week.  Do you agree with the dx and what do you think follow up should be?

[Thomas D Schiano, MD]

i do not think this is plqvix-hepatitis.  I have not heard of this although it can be possible.  Sounds to me like you may have passed a gallstone.  plavix can cause a hemolytic-uremic syndrome and TTP will low platelets, etc.  The plavix may have given you a systemic reaction.  i think watchful waiting for now is OK with careful monitoring of your liver tests.

[codiver]

Thank you for your time and expertise.