University of Wisconsin–Madison Medical College of Wisconsin

A Case of Progressive Cholestatic Drug-Induced Liver Injury Due to Terbinafine

Dana Ley, MD; Jessica Musto, MD; Adnan Said, MD, MS

WMJ. 2023;122(2):138-142.

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Introduction: Terbinafine is commonly prescribed for onychomycosis. It rarely leads to severe, prolonged cholestatic drug-induced liver injury. Clinicians should remain vigilant for this complication.

Case Presentation: A 62-year-old woman was started on terbinafine and developed mixed hepatocellular and cholestatic drug-induced liver injury, confirmed on liver biopsy. The injury became predominantly cholestatic. Unfortunately, she developed coagulopathy with elevated international normalized ratio and progressive drug-induced liver injury with severely elevated alkaline phosphatase and total bilirubin, requiring repeat liver biopsy. Fortunately, she did not develop acute liver failure.

Discussion: Prior case reports and series have documented severe cholestatic drug-induced liver injury (although with lesser degree of bilirubin elevation) due to terbinafine, which has very rarely been associated with acute liver failure, need for liver transplantation, and/or death.

Conclusions: Non-acetaminophen drug-induced liver injury is idiosyncratic. Complications including acute liver failure and vanishing bile duct syndrome can be slow to develop, so monitoring for them is important over longitudinal follow-up.

Author Affiliations: University of Wisconsin Hospitals and Clinics, Department of Medicine, Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (Ley, Musto, Said); William S. Middleton Memorial Veterans Hospital, Madison, Wis (Said).
Corresponding Author: Dana Ley, MD, 1685 Highland Ave, Ste 4000, Madison, WI 53705, phone 608.263.1995; email
Funding/Support: None declared.
Financial Disclosures: None declared.
Acknowledgements: Informed consent was obtained from the patient via telephone on August 30, 2021.
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