Rifampicin Induced Hyperbilirubinemias: A Case Report.

Abstract Anti-tubercular therapy (ATT) induced hepatitis is a major problem which a physician encounters in his clinical practice. A case of 28-year old female, weighing 45 kg was brought to hospital with the chief complains of low-grade fever for the past two months, cough, shortness of breath and 4-5 kg weight loss in two months. She had no history of hypertension (HTN), diabetes mellitus (DM), pulmonary tuberculosis (PTB). Her Chest X-ray showed right sided bilateral pulmonary TB and sputum acid fast bacilli (AFB) smear was repeatedly positive. Pulmonologist has started Category-I anti-tubercular regimen (Rifampicin, Isoniazid, Pyrazinamide and Ethambutol) under DOTS as per RNTCP guidelines. After 7 days of starting the treatment (DOTS regimen), she noticed yellowish discoloration of sclera, orange discoloration of urine but in spite of this she continued the drug for a further two weeks. Patient was found to be developing hepatotoxicity with the findings of elevated total bilirubin (10.2 mg/dl), conjugated bilirubin (2.5 mg/dl) and unconjugated bilirubin (7.2 mg/dl). Viral markers for hepatitis including hepatitis B viruses (HBsAg), hepatitis C viruses (HCV), human immunodeficiency virus (HIV), were all are non-reactive. Pulmonologist made provisional diagnosis of anti-tubercular drugs (specially rifampicin) induced hyperbilirubinemias. Pulmonologist initially hold Rifampicin and Pyrazinamide, but started Isoniazid, Ethambutol, Ofloxacin, Pyridoxine along with liver enzyme. She showed gradual improvement as bilirubin after one-week had dropped down to 1.2 mg/dl. Rifampicin was added to the regimen and the serum bilirubin checked after 1 week was found 1 mg/dl. Pyrazinamide was added after repeated LFTs showed normal values. Patient continued her drugs and came for review after three months. She was advised to continue and complete the course of anti-tubercular drugs. Since Rifampicin is the most important first line anti-tubercular drug it is very important to restart this drug in order to have a satisfactory response to anti-tubercular therapy. We have reported this case because of its rarity in clinical practice. As a health care team member clinical pharmacist are need to be made aware of these potentially fatal adverse effects associated with anti-tubercular therapy via conduction of quality-based seminars, published medical literature, conferences, learning programs and health care camps.