A rare case of drug-induced liver injury caused by an epinephrine-autoinjector

Drug-induced liver injury (DILI) is the most common cause of acute liver failure in the USA. It is a diagnosis of exclusion based on history, physical examination, laboratory investigations and in some instances liver biopsy. Herein we present a case of a previously healthy young man who developed severe jaundice and elevated liver function tests [alanine transaminase (ALT) 700 U/L, aspartate transaminase (AST) 394 U/L, alkaline phosphatase (ALP) 636 U/L, gamma-glutamyl transpeptidase (GGT) 361 U/L, total bilirubin 26.67 mg/dL and conjugated bilirubin 16.05 mg/dL] after the inappropriate use of an epinephrine autoinjector. DILI was diagnosed after exclusion of all other possible causes. R value <2 suggestive of cholestatic liver injury, RUCAM score was 9 and consistent with high probability of DILI. Liver biopsy confirmed the diagnosis. Liver function tests returned to normal within several months. Sodium metabisulfite the preservative added to the epinephrine autoinjector has been reported to cause liver injury in an animal model. In the absence of any other medication, herbal preparation or supplements and the recent use of the epinephrine-autoinjector, sodium metabisulfite is the most likely cause of the patients DILI. Detailed history and investigations with the assistance of assessment tools led to the culprit. Preservatives and excipients used in medical preparations are not without harm and must be thoroughly evaluated in the right clinical context.