RESUMO
Drug induced liver injury (DILI) has been a long-standing concern in the treatment of tuberculosis. Anti-tuberculosis therapy (ATT) is known to have hepatotoxicity effect. DILI is diagnosed clinically using liver biochemical test, such as alanine transaminase (ALT), alkaline phosphatase (ALP), and total bilirubin. Calculating ratio (R) of ALT over ALP, is useful to classify types of injury pattern in DILI. Roussel Uclaf causality assessment method (RUCAM)scaleserves as a method to assess the causality agents for DILI. Here we report a case of 59 years old male who developed cholestatic DILI on fourth weeks of ATT. Patient came in with loss of consciousness, jaundice, nausea, pruritus, and abdominal tenderness. Patient抯 ALT level was normal, but ALP and total bilirubin was significantly elevated, with R values less than 2, indicating a cholestatic type of injury. Patient sputum was positive for tuberculosis bacteria, showing an active infection. Patient was admitted and ATT was discontinued. Patient showed improvement, but eventually fall into sepsis and developed respiratory distress on sixth day of admission despite adequate treatment and close monitoring. Despite most of the cases resolves spontaneously upon cessation of the toxic agents, in the severe form, it may fall into chronic liver injury, acute liver failure, and eventually death. Preventing DILI is readily important by educating, screening for risk factors, and routine evaluation of liver enzymes in patient under ATT. Early diagnosis and prompt treatment are needed to avoid poor prognosis in the course of the disease.
RESUMO
COVID-19 pandemic in dengue endemic countries has becoming a concern due to its similarities in early clinical symptoms and laboratory features. The cases of co-infection between the two diseases are inevitable and associated with higher morbidity and mortality. Here we presented a case of a 28 years old female diagnosed with co-infection of COVID-19 and dengue hemorrhagic fever that complicated with severe thrombocytopenia and spontaneous bleeding.She came with fever that started 3 days prior to admission. Laboratory examination showed leucopenia, thrombocytopenia, elevated liver enzymes, and D-dimer. Patient tested positive for non-structural protein 1 (NS-1)dengue antigen. She had a pre-screening rapid test for COVID-19 as part of hospital protocol, and she tested positive. Followed by positive COVID-19 reverse transcriptase-polymerase chain reaction (RT-PCR)test confirmingthe diagnosis. During admission, patient started menstruating, resulting in active spontaneous bleeding while platelet counts dropped to below 10×109/l. Patient was given platelet transfusion, supportive therapy and put under close monitoring. The case ofco-infection between COVID-19 and dengue is inevitable in tropical and sub-tropical countries. Both infections shared similar pathophysiology through different mechanism, such as plasma leakage, thrombocytopenia, and coagulopathy.Complications may arise and physician must aware of the therapeutical approach. Diagnostic testing must not be withheld when there was suspicion towards the infection. Prompt treatment and close monitoring can result in good prognosis.