Liver enzyme abnormalities in systemic lupus erythematosus: a focus on toxic hepatitis

Although subclinical liver disease is common in systemic lupus erythematosus (SLE), strikingly high levels of liver enzymes are rare. Our aim was to determine the cause of high levels of liver enzymes in lupus patients, particularly in patients diagnosed with toxic hepatitis. We performed a retrospective chart review of SLE patients treated at the Inje University Hospital between 2001 and 2008. We defined liver enzyme abnormality as a twofold or greater increase in two or more of the following four components: total bilirubin, AST, ALT and LDH or ALP. Acute toxic hepatitis was diagnosed by a score ≥5 in the Roussel Uclaf Causality Assessment Method. Of 141 SLE patients 46 (32.6%) met strict criteria for the liver enzyme abnormality. In total, 11 patients (7.8%) in this study had presumed toxic hepatitis associated with either herbal medicines (n = 6), anti-tuberculosis medications (n = 3), antibiotics (n = 1) or valproic acid (n = 1). There were striking laboratory abnormalities in the groups diagnosed with toxic hepatitis (mean peak values: AST 775 ± 464 U/L, ALT 400 ± 447 U/L, ALP 767 ± 408 U/L, LDH 1,469 ± 779 U/L). All six patients with herbal-induced toxic hepatitis were in the active SLE state. After cessation of the suspected causative medication and subsequent administration of steroids, liver enzyme levels were improved. Herbal medicines and anti-tuberculosis medications, known to cause toxic hepatitis, can also induce increased liver enzyme levels in lupus patients. However, since most herbal medicines contain a mixture of various products, we could not ascertain what specific ingredient induced the increase in liver enzyme levels.