Posaconazole-associated severe hyperbilirubinemia in acute myeloid leukemia following chemotherapy: A case report

BACKGROUND: Posaconazole is a widely used azole antifungal agent, and posaconazole-associated severe hyperbilirubinemia is usually rare in clinical practice. We herein report a 58-year-old male with acute myeloid leukemia, who developed fungal infection following chemotherapy. CASE SUMMARY: After administration of posaconazole oral suspension, the patient developed severe hyperbilirubinemia and jaundice (Common Terminology Criteria for Adverse Events, CTCAE -Grade 3) with a serum total bilirubin (T-BIL) peak level of 170 μmol/L, alkaline phosphatase level of 739 U/L, alanine aminotransferase level of 99 U/L, and gamma-glutamyl transpeptidase level of 638 U/L. After posaconazole withdrawal and symptomatic treatment with liver-protective agents, the level of T-BIL and other laboratory data decreased gradually, and related symptoms disappeared. After medication analysis and literature review, we consider that the patient had a cholestatic type of posaconazole-induced liver injury, which was related to intracellular mitochondrial DNA damage. The case demonstrates that when patients with hematological malignancy develop severe infection following chemotherapy, combination of anti-infective drugs may contribute to a higher risk of severe drug-induced liver injury. CONCLUSION: This is the first thoroughly documented case report of posaconazole-associated severe hyperbilirubinemia. Therefore, in order to avoid severe adverse events, liver and renal function should be monitored closely before and during the administration of posaconazole.