Case Report: A Patient with Gout Develops Granulomatous Hepatitis

inflammatory agent during initiation to prevent these flares.

Also possible are numerous delayed hypersensitivity reactions, such as maculopapular exanthema, Stevens-Johnson syndrome, toxic epidermal necrolysis, and drug rash with eosinophilia and systemic symptoms. Patients who are HLA-B*5801-genotype positive are at higher risk of developing these cutaneous reactions and should avoid allopurinol. This genotype is most often seen in patients of Korean, Han Chinese or Thai heritage.⁶

Other adverse effects seen with allopurinol use include gastrointestinal upset (e.g., nausea, diarrhea), drowsiness, leukopenia and thrombocytopenia.⁶

Conclusion

Allopurinol-induced granulomatous hepatitis is a rare phenomenon that rheumatologists should be aware of given the frequency with which this drug is used. A discovery of this condition should prompt a change in therapy to another urate-lowering agent, such as febuxostat, which has not had any reported cases of granulomatous hepatitis.

This case serves as a reminder that any clinical presentation without a clear etiology warrants a review of the patient’s medication list. It is not possible to know every rare, adverse reaction to medications, but identifying a temporal relationship between a drug and a clinical presentation can help guide our clinical suspicions.  

Raj Vachhani, MD, is a third-year postgraduate, studying internal medicine at the University of Alabama, Birmingham.

Angelo L. Gaffo, MD, MSPH, is the rheuma­tology section chief at the Birmingham VA Medical Center and associate professor of medicine in the Division of Rheumatology at the University of Alabama, Birmingham.

References

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