Case Report
Copyright ©The Author(s) 2015.
World J Hepatol. Feb 27, 2015; 7(2): 285-288
Published online Feb 27, 2015. doi: 10.4254/wjh.v7.i2.285
Table 1 Score of the presented patient according to Council for International Organizations of Medical Sciences Scale
Items for hepatocellular injuryScoreResult of the presented case1
1 Time to onset from the beginning of the drug/herb
5-90 d (rechallenge: 1-15 d)2+
< 5 or > 90 d (rechallenge: > 15 d)1-
Alternative: Time to onset from cessation of the drug/herb
≤ 15 d (except for slowly metabolized chemicals: > 15 d)1-
2 Course of ALT after cessation of the drug/herb
Percentage difference between ALT peak and N
Decrease ≥ 50% within 8 d3+
Decrease ≥ 50% within 30 d2-
No information or continued drug/herb use0-
Decrease ≥ 50% after the 30th day0-
Decrease < 50% after the 30th day or recurrent increase-2-
3 Risk factors
Alcohol use (drinks/d: > 2 for women, > 3 for men)1-
Alcohol use (drinks/d: ≤ 2 for women, ≤ 3 for men)0+
Age ≥ 55 yr1-
Age < 55 yr0+
4 Concomitant drug(s) or herbs(s)
None or no information0-
Concomitant drug or herb with incompatible time to onset0+
Concomitant drug or herb with compatible or suggestive time to onset-1-
Concomitant drug or herb known as hepatotoxin and with compatible or suggestive time to onset-2-
Concomitant drug or herb with evidence for its role in this case (positive rechallenge or validated test)-3-
5 Search for non drug/herb causes“+” if negative-
Group I (6 causes)
HBsAg, anti-HBc-IgM, HBV-DNA+-
Hepatobiliary sonography/colour doppler sonography of liver vessels/endosonography/CT/MRC+-
Alcoholism (AST/ALT ≥ 2)+-
Acute recent hypotension history (particularly if underlying heart disease)+-
Group II (6 causes)
Complications of underlying disease(s) such as sepsis, autoimmune hepatitis, chronic hepatitis B or C, primary biliary cirrhosis or sclerosing cholangitis, genetic liver diseases+-
Infection suggested by PCR and titer change for CMV (anti-CMV-IgM, anti-CMV-IgG)+-
EBV (anti-EBV-IgM, anti-EBV-IgG)+-
HEV (anti-HEV-IgM, anti-HEV-IgG)+-
HSV (anti-HSV-IgM, anti-HSV-IgG)+-
VZV (anti-VZV-IgM, anti-VZV-IgG)+-
Evaluation of group I and II
All causes-groups I and II - reasonably ruled out2+
The 6 causes of group I ruled out1-
5 or 4 causes of group I ruled out0-
Less than 4 causes of group I ruled out-2-
Non drug or herb cause highly probable-3-
6 Previous information on hepatotoxicity of the drug/herb
Reaction labelled in the product characteristics2-
Reaction published but unlabelled1-
Reaction unknown0+
7 Response to unintentional readministration
Doubling of ALT with the drug/herb alone, provided ALT below 5N before reexposure3-
Doubling of ALT with the drug(s) and herb(s) already given at the time of first reaction1-
Increase of ALT but less than N in the same conditions as for the first administration-2-
Other situations0+
Total Score7