Delayed diagnosis of cholestatic drug-induced liver injury treated with corticosteroid for adrenal insufficiency secondary to miliary tuberculosis

Drug-induced liver injury (DILI) in a patient with multiple comorbidities is often challenging to diagnose because liver injury can be attributed to multiple disease processes. Delayed treatment of DILI could have fatal consequences and, therefore, understanding the features and risks of DILI is crucial. We report a unique case of a patient who was admitted for severe sepsis of unknown etiology. This patient was later found to have miliary tuberculosis (TB) with associated adrenal insufficiency, complicated by acute cholestatic liver injury. Liver injury fully improved after initiation of corticosteroid for the treatment of adrenal insufficiency. The most likely pathophysiology of acute liver injury was DILI, given the clinical course of liver injury and the liver biopsy result of non-caseating granulomas. Although five different antibiotics including ciprofloxacin, metronidazole, vancomycin, imipenem/cilastatin, and cefepime were provided, the timing of liver injury and pharmacology of each drug imply that ciprofloxacin was the most likely antibiotic causing DILI, given the pharmacology of each antibiotics. This case is unique because miliary TB was complicated by adrenal insufficiency and drug-induced cholestatic liver injury, but acute liver injury was fully reversed after corticosteroid treatment. This implies an immune-mediated etiology of DILI, especially ciprofloxacin-induced cholestatic liver injury. DILI is challenging to diagnose in the setting of multiple comorbidities. Therefore, it is crucial that clinicians are to be aware of signs and symptoms of DILI, in that delayed diagnose and treatment may have fatal consequences.