This is a 56 year old woman with hypertension, diabetes, hyperlipidemia, asthma and osteoarthritis, who presented with of abdominal pain and diarrhoea, associated with significant increase in ALT and AST. She had a recent inpatient negative work up for viral and autoimmune hepatitis. Her liver enzymes started to trend down gradually, but she developed fever, nausea and vomiting. On an abdomen CT scan she had fatty liver without focal hepatic lesions with an incidental finding of Patchy ground‐glass airspace opacity within the superior segment of lower lobes bilaterally. She was started on outpatient azithromycin for pneumonia, however she became more short of breath and was admitted to the hospital and started on IV antibiotics and then Limbrel (which she was started 3 months ago) was discontinued. She had leukocytosis, elevated ESR, CRP and ACE levels but she had negative blood and sputum cultures, urine legionella antigen, and HIV. Chest CT scan showed multifocal areas of patchy groundglass density. She didn’t improve on 5 days of antibiotics but then she was started on steroid for suspected hypersensitivity pneumonitis. Bronchoscope was done and BAL sample showed 10% lymphocytes, 9% neutrophils, 50 % macrophages and negative cultures, and AFB. Lung biopsy was not possible because the patient was desaturating during the procedure. PFT showed normal lung volumes and spirometery but impaired DLCO. In 2 days after steroids she started to improve clinically. 2 weeks later, sed rate and leukocytosis normalized, and Chest X‐ray showed resolution of infiltrates. Liver enzymes continued to improve gradually.
Hypersensitivity pneumonitis (HP) is a complex syndrome of varying intensity, and clinical presentation. Patients usually present with fever, cough, dyspnea and lungs infiltrates following exposure to inciting agents (e.g.: agricultural dusts, bioaerosols, microorganism, and certain reactive chemicals). Recently an association between Flavocoxide and HP has been reported. Diagnosis is made usually based on history of exposure or re‐exposure, clinical picture and resolution after stopping the inciting factor. Diagnosis can be confirmed with BAL (with low CD4/CD8 ratio) and biopsy.
This case demonstrates the association between Flavocoxide use and hypersensitivity pneumonitis as well as transaminitis. Flavocoxide is an anti‐inflammatory, cyclooxygenase and lipoxygenase inhibitor that has been used for osteoarthritis since 2004. It is known to be safe, but rarely causes acute liver injury. Hypersensitivity pneumonitis due to use of Limbrel was repored in rare cases since 2008. Stopping limbrel resolves the disease but steroids may be indicated in sever or persistent cases.