[CMV associated acute liver failure in a patient receiving tocilizumab for systemic lupus erythematosus]

A 41-year-old female patient was admitted because of febrile jaundice and acute liver failure. The quick and the bilirubin were 21 % and 258 µmol/l, and there was hepatic encephalopathy I°. AST and AP had a maximum of 612 and 215 U/l. Despite a strong left shift in the differential, the CRP had a maximum of 15 mg/l. Because of an atypically presenting systemic lupus erythematosus, she had been treated with Azathioprine, steroids and Tocilizumab until 12 days before admission. The diagnostic workup revealed CMV hepatitis and necrotizing hepatopathy, which was interpreted as toxic hepatitis. At the time of liver biopsy, on day 3 after admission, staining for Ki-67 indicated strong regenerative activity in the liver. Treatment with Valgancyclovir, antibiotics and steroids led to early recovery from liver failure. The case differs from the few described cases of severe acute liver injury related to Tocilizumab. Apparently, the combined immunosuppression (steroid, Azathioprine and Tocilizumab) led to acute liver failure secondary to CMV hepatitis and acute toxic hepatitis, which may have been aggravated by transiently impaired liver regeneration. On the other hand, stimulated liver regeneration was proven by histology despite previous IL6 blockage by Tocilizumab.