Periportal necrosis and successful liver transplantation following Lamotrigine drug-induced liver injury in a child

Abstract

Lamotrigine is one of the most prescribed antiepileptics in children and a well-known cause of drug-induced liver injury (DILI). The typical presentation usually includes a drug rash with eosinophilia and systemic symptoms (DRESS syndrome). Cases are typically mild and self-limiting, requiring supportive care only. We report a severe Lamotrigine-induced DILI with a non-typical presentation with hyperammonaemia and rapid clinical deterioration. We present a literature review exploring contributing factors, transplant considerations and liver histology. Histology showed periportal necrosis, which is recognised as a pattern of DILI but has not been previously described with Lamotrigine. Our patient proceeded to transplant and is the first reported liver transplant for Lamotrigine DILI in a child. A directed and rapid diagnostic approach is crucial to avoid delays and rule out multisystemic metabolic and genetic conditions that preclude liver transplantation.

Keywords: Gastrointestinal system; Hepatitis other; Paediatrics; Paediatrics (drugs and medicines).

Figure 1

Upper left, H&E ×40. Necrosis is seen linking portal tracts ‘PT’, parenchyma around the central vein (‘CV’) is viable. Top right, reticulin ×40. Collapse of the reticulin framework is seen in the portal/portal necrotic bridges. Bottom left, H&E ×200. There is a zone of necrosis, marked by the arrow, around a portal tract. Bottom right, H&E ×200. Viable parenchyma around the central vein shows marked canalicular cholestasis and hepatocyte ballooning.