[Phenprocoumon-induced cholestatic hepatitis]

A 78-year-old woman had 4 years age received phenprocoumon as prophylaxis against thromboembolism after implantation 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 and she again received phenprocoumon. She was admitted now because of cholestatic jaundice with rapid deterioration of her general state. There were no significant abnormal findings other than jaundiced skin and sclerae.

Bilirubin concentration was clearly elevated to 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 antibodies, but negative for B and C antibodies. No antigens were demonstrated. The eosinophil count was elevated in the differential blood count. Sonography showed a normal-sized liver with slightly dense echo pattern, but no evidence of abscess or dilatation of the bile duct system. Liver biopsy revealed severe acute hepatitis of viral type and discrete eosinophilic infiltration.

After all medication had been discontinued, transaminase activities decreased while bilirubin concentration rose. Thus, prednisone treatment was started (initially 50 mg/d), the dose then gradually reduced. The cholestasis parameters became normal and the patient's general state was much improved so that she could be discharged.

Cholestatic hepatitis is a rare side effect of phenprocoumon. The associated eosinophilia suggests the cause to be an allergic genesis in the sense of a hypersensitivity reaction.