Drug-induced liver injury from high-dose intravenous methylprednisolone: A rare but known adverse effect

Table 1 Complete metabolic panel showing elevated liver enzymes the following day after high-dose methylprednisolone

Variable	Patient values	Normal range
AST	224	15-41 U/L
Alkaline phosphatase	111	32-91 U/L
Total bilirubin	0.8	0.3-1.0 mg/dL
Calcium	9.1	8.6-10.4 mg/dL
Total protein	6.4	5.8-8.2 g/dL
Albumin	4.0	3.5-5.1 g/dL
Glucose, blood	211	70-139 mg/dL
BUN	16	6-20 mg/dL
Creatinine	0.60	0.44-1.03 mg/dL
BUN/creatinine ratio	24.2	10.0-20.0 mgUN/mgCR
Sodium, blood	141	136-145 mmol/L
Potassium, blood	4.4	3.5-5.1 mmol/L
Chloride, blood	107	98-107 mmol/L
Osmolality, calculated	298	275-295 mOsm/kg
CO2	25	22-32 mmol/L
Anion gap	9	4-15 mmol/L
ALT	233	7-52 U/L
CKD-EPI eGFR	100	> 59 mL/minute/1.73 m2

AST: Aspartate aminotransferase; BUN: Blood urea nitrogen; UN: Urea nitrogen; CR: Creatinine; ALT: Alanine aminotransferase; CKD-EPI eGFR: Chronic kidney disease epidemiology collaboration equation for estimating glomerular filtration rate.

Table 2 Naranjo adverse drug reaction probability scale for the patient

Question	Yes	No	Do not know	Score
Are there previous conclusive reports on this reaction?	+ 1	0	0	+ 1
Did the adverse event appear after the suspected drug was administered?	+ 2	- 1	0	+ 2
Did the adverse reaction improve when the drug was discontinued or a specific antagonist was administered?	+ 1	0	0	+ 1
Did the adverse reaction reappear when the drug was readministered?	+ 2	- 1	0	0
Are there alternative causes (other than the drug) that could on their own have caused the reaction?	- 1	+ 2	0	+ 2
Did the reaction reappear when a placebo was given?	- 1	+ 1	0	0
Was the drug detected in the blood (or other fluids) in concentrations known to be toxic?	+ 1	0	0	0
Was the reaction more severe when the dose was increased or less severe when the dose was decreased?	+ 1	0	0	0
Did the patient have a similar reaction to the same or similar drugs in any previous exposure?	+ 1	0	0	0
Was the adverse event confirmed by any objective evidence?	+ 1	0	0	+ 1
Total score				7