case_images: PMC6076919_01
case_images: Patient's liver enzyme levels and level of immunosuppression after receiving a liver transplant in July 2015. The blue arrow represents the date of the transplant and the shaded area between the red arrows represents the everolimus exposure period (start: 9/3/15; end: 12/1/15).
case_images: CRIT2018-7410508.001.jpg
case_images: PMC6076919_01_CRIT2018-7410508.001.jpg
case_images: fig1
case_images: The patient remained stable on this regimen and had the following normal laboratory results at the beginning of September (Figure 1): ALT 32 IU/L (normal=0-40), AST 23 IU/L (normal= 5-40), alkaline phosphatase (ALP) 83 IU/L (normal= 40-100), gamma-glutamyl transpeptidase (GGT) 36 IU/L (normal=10-64), total bilirubin 0.3 mg/dL (normal=0.3-1.9 mg/dL), BUN 26 (normal 6-20 mg/dL), and Scr 1.18 (normal 0.67-1.17 mg/dL) and INR 1.1. The everolimus trough was subtherapeutic until late October when a trough of 3.8 ng/mL was achieved on a dose of 3 mg PO qam and 2.5 mg PO qpm (Figure 1).
case_images: Patient's second biopsy done on 11/30/2015 showing features of DILI including portal eosinophils and rare acidophil bodies.
case_images: CRIT2018-7410508.002.jpg
case_images: PMC6076919_01_CRIT2018-7410508.002.jpg
case_images: fig2
case_images: A second liver biopsy was done on 11/30/15 that showed mild patchy sinusoidal dilatation and focal mild inflammatory infiltrate with lymphocytes, eosinophils, and rare acidophil bodies (Figure 2).