Supplementary Material for: A Patient with Nafcillin-Associated Drug-Induced Liver Failure

Nafcillin-induced acute liver injury is a rare and potentially fatal complication that has been known since the 1960s but inadequately studied. At this time, the only proven treatment is early discontinuation of the drug. Because of the high prevalence of nafcillin class antibiotic use in the United States, it is important for clinicians to have a high clinical suspicion for this diagnosis. We present a case of liver failure attributable to nafcillin use in a 68-year-old male with a history methicillin-sensitive <i>Staphylococcus</i> and L3/L4 osteomyelitis. After starting long-term antibiotic therapy, he presented with painless jaundice which necessitated discontinuation of the drug. At the time of presentation, the patient’s lab work exhibited a bilirubin/direct bilirubin of 9.4/8.2 mg/dL, alkaline phosphatase of 311 IU/L, and aspartate transaminase/alanine transaminase of 109/127 IU/L. The patient was switched to i.v. vancomycin given the concern for drug-induced liver injury. Imaging did not show obstruction of the hepatobiliary or pancreaticobiliary trees. Serology was unremarkable for viral etiology, autoimmune processes, Wilson disease, and hemochromatosis. A liver biopsy showed findings consistent with drug-induced liver injury. The patient’s liver function tests peaked at day 7 of admission and trended towards normal levels with cessation of nafcillin therapy. The patient was discharged with a diagnosis of nafcillin-induced acute liver injury. Our case highlights the importance of early recognition of the diagnosis and careful monitoring of liver function when nafcillin is employed in the clinical setting.

萘夫西林诱导的急性肝损伤（nafcillin-induced acute liver injury）是一种罕见且潜在致命的并发症，自20世纪60年代起便已被学界认知，但相关研究仍不够充分。目前，经证实的唯一治疗方案为尽早停用该药物。鉴于美国境内萘夫西林类抗生素的临床使用比例较高，临床医生对该诊断保持高度的临床警惕性具有重要意义。本文报告1例68岁男性患者因使用萘夫西林导致肝衰竭的病例，该患者既往有甲氧西林敏感葡萄球菌（methicillin-sensitive Staphylococcus）感染及L3/L4椎体骨髓炎病史。在开始长期抗生素治疗后，患者出现无痛性黄疸，因此不得不停用萘夫西林。就诊时，患者的实验室检查结果显示总胆红素/直接胆红素为9.4/8.2 mg/dL，碱性磷酸酶为311 IU/L，天冬氨酸转氨酶/丙氨酸转氨酶为109/127 IU/L。因怀疑为药物性肝损伤，患者换用静脉注射（i.v.）万古霉素（vancomycin）。影像学检查未发现肝胆系统及胰胆管系统存在梗阻。血清学检测未发现病毒性病因、自身免疫性疾病、威尔逊病（Wilson disease）及血色病（hemochromatosis）相关异常。肝活检结果符合药物性肝损伤的病理表现。患者的肝功能指标在入院第7天达到峰值，停用萘夫西林治疗后逐渐恢复至正常水平。患者最终确诊为萘夫西林诱导的急性肝损伤并出院。本病例凸显了临床应用萘夫西林时，尽早明确该诊断并密切监测肝功能的重要性。