PHENPROCOUMON-INDUCED CHOLESTATIC HEPATIT IS

History and clinical findings: A 78-year-old woman had 4 years ago rec eived phenprocoumon as prophylaxis against thromboembolism after impla ntation of a left total knee prosthesis. Ten weeks later she developed hepatitis with negative hepatitis serology. 6 weeks before her latest hospitalisation a right total knee implantation had been performed an d she again received phenprocoumon. She was admitted now because of ch olestatic jaundice with rapid deterioration of her general state. Ther e were no significant abnormal findings other than jaundiced skin and sclerae. Investigation: Bilirubin concentration was clearly elevated t o 11.5 mg/dl, and the transaminase activities were increased, together with raised gamma-GT and alkaline phosphatase levels. The Quick value was below 8%. Hepatitis serology was positive for hepatitis A antibod ies, but negative for B and C antibodies. No antigens were demonstrate d. The eosinophil count was elevated in the differential blood count. Sonography showed a normal-sized liver with slightly dense echo patter n, but no evidence of abscess or dilatation of the bile duct system. L iver biopsy revealed severe acute hepatitis of viral type and discrete eosinophilic infiltration. Treatment and course: After all medication had been discontinued, transaminase activities ties decreased while b ilirubin concentration rose. Thus, prednisone treatment was started (i nitially 50 mg/d), the dose then gradually reduced. The cholestasis pa rameters became normal and the patient's general state was much improv ed so that she could be discharged. Conclusion: Cholestatic hepatitis is a rare side effect of phenprocoumon. The associated eosinophilia su ggests the cause to be an allergic genesis in the sense of a hypersens itivity reaction.