What is the management for a patient with elevated Serum Glutamic-Pyruvic Transaminase (SGPT) 4 times the normal range and elevated eosinophils?

Management of SGPT Elevated 4x Normal with Elevated Eosinophils

Immediate Action: Rule Out Parasitic Infection Before Any Immunosuppression

Do not initiate corticosteroids or any immunosuppressive therapy until Strongyloides stercoralis is definitively excluded, as this can precipitate fatal hyperinfection syndrome. 1, 2

Priority 1: Urgent Parasitic Workup (Within 24-48 Hours)

The combination of transaminitis and eosinophilia strongly suggests helminthic infection, particularly liver flukes or tissue-invasive parasites. 2, 3

Essential History Elements

• Travel exposure: Document any travel to Latin America, Southeast Asia, Eastern Europe, or Middle East within the past several years (parasites can remain dormant) 2
• Dietary history: Raw/undercooked freshwater fish, crab, crayfish (Clonorchis, Opisthorchis), raw pork (trichinellosis), or watercress (Fasciola hepatica) 2
• Medication review: All drugs and supplements started within 6 months, as drug-induced liver injury with eosinophilia (DILI) mimics autoimmune hepatitis in 9-17% of cases 4
• Fresh water exposure: Swimming or wading in endemic schistosomiasis regions 1

Immediate Laboratory Testing

• Three separate concentrated stool specimens for ova and parasites (though sensitivity is low for liver flukes in chronic phase) 1, 2
• Parasite-specific serology: Strongyloides, Fasciola hepatica, Schistosoma species, liver flukes (Clonorchis, Opisthorchis), Toxocara 1, 2
• Complete metabolic panel to characterize hepatocellular vs cholestatic pattern 2
• Serum IgE levels (typically elevated in parasitic infections) 2, 5

Imaging

• Abdominal ultrasound as first-line to evaluate for hepatic cysts (hydatid disease), biliary obstruction (liver flukes), or characteristic migration tracks (acute fascioliasis) 2
• CT or MRI if ultrasound abnormal or if suspicion remains high despite negative ultrasound 2

Priority 2: Assess for Drug-Induced Liver Injury

If SGPT >5x ULN (Grade 3), immediately discontinue all non-essential medications and known hepatotoxic drugs. 4

DILI with Eosinophilia Characteristics

• Presents with fever, rash, and elevated eosinophils in ~30% of cases 4
• Common causative agents: nitrofurantoin, minocycline, alpha-methyldopa, hydralazine 4
• Latency period varies: 1-8 weeks to 3-12 months after drug exposure 4
• Key distinguishing feature: DILI improves within 1 month of drug cessation without recurrence after steroid withdrawal, whereas autoimmune hepatitis relapses 4

Management Based on Transaminase Level

Grade 2 (SGPT 3-5x ULN):

• Hold all potentially hepatotoxic agents 4
• Monitor liver enzymes every 3 days 4
• If no improvement after 3-5 days of drug cessation, consider prednisone 0.5-1 mg/kg/day 4
• Do NOT start steroids until parasitic workup complete 1, 2

Grade 3 (SGPT 5-20x ULN) - Your Patient:

• Immediately discontinue all non-essential medications 4
• Hold steroids pending parasitic exclusion 1, 2
• Monitor liver enzymes every 3 days 4
• Hepatology consultation recommended 4

Grade 4 (SGPT >20x ULN or bilirubin >10x ULN):

• Permanently discontinue suspected causative agent 4
• Inpatient management required 4
• Methylprednisolone 1-2 mg/kg/day IV (only after Strongyloides excluded) 4

Priority 3: Empiric Antiparasitic Treatment

For patients with travel history to endemic regions, initiate empiric treatment while awaiting serology results: 2, 5

• Albendazole 400 mg single dose PLUS Ivermectin 200 μg/kg single dose 2, 5
• This covers Strongyloides, Ascaris, hookworm, and other common helminths 1, 2

Specific Treatments if Identified

• Fasciola hepatica: Triclabendazole 10 mg/kg single dose 2
• Liver flukes (Clonorchis, Opisthorchis): Praziquantel 25 mg/kg three times daily for 2 days 2
• Strongyloides: Ivermectin 200 μg/kg daily for 1-2 days 1, 2
• Schistosomiasis: Praziquantel 40 mg/kg single dose, repeat at 6-8 weeks 1

Critical Warning for Loa loa

If blood film shows microfilariae, do NOT use diethylcarbamazine (DEC) as it may cause fatal encephalopathy. Use corticosteroids with albendazole first to reduce microfilarial load to <1000/mL before definitive treatment. 1, 2

Priority 4: Assess for End-Organ Damage from Eosinophilia

With eosinophil count of 9 x 10⁹/L (severe hypereosinophilia), urgent evaluation for cardiac, pulmonary, and neurologic involvement is mandatory. 1

Cardiac Assessment (Most Critical)

• ECG, cardiac troponin, NT-proBNP immediately 1
• Echocardiography if troponin elevated or any cardiac symptoms (chest pain, dyspnea, palpitations) 1
• Cardiac MRI if troponin elevated to distinguish eosinophilic cardiac disease from other etiologies 1

Pulmonary Assessment

• Chest X-ray to identify infiltrates 1
• Pulmonary function tests if respiratory symptoms present 1

Neurologic Assessment

• Electromyography if sensory or motor deficits present 1

Priority 5: Monitor and Reassess

If Parasitic Workup Negative and Drug Cessation Ineffective After 3-5 Days:

Consider steroid trial: Prednisone 0.5-1 mg/kg/day for Grade 3 hepatitis 4

• If inadequate improvement after 3 days, add mycophenolate mofetil 500-1000 mg twice daily 4
• Never use infliximab for hepatic involvement (contraindicated due to hepatotoxicity risk) 4

Liver Biopsy Indications

• Steroid-refractory hepatitis 4
• Uncertainty between DILI and autoimmune hepatitis 4
• Persistent elevation despite treatment 4

Hematology Referral

Refer to hematology if eosinophilia ≥1.5 x 10⁹/L persists >3 months after infectious causes excluded or treated, or if end-organ damage present. 1, 5

Workup will include bone marrow biopsy with cytogenetics, FISH for PDGFRA/PDGFRB/FGFR1 rearrangements, and flow cytometry for aberrant T-cell populations. 5

Critical Pitfalls to Avoid

• Never start corticosteroids before excluding Strongyloides - risk of fatal hyperinfection syndrome 1, 2
• Normal eosinophil counts do not exclude parasitic infection - many helminth-infected patients have normal counts 1, 2
• Serology may be negative in early infection (prepatent period 3-5 weeks for Fasciola, 4 weeks for liver flukes) 2
• Do not assume improvement means DILI - monitor for 3 months after steroid withdrawal, as relapse indicates autoimmune hepatitis 4
• Infliximab is absolutely contraindicated for hepatic immune-related adverse events 4