Anti-tuberculosis drug-induced liver injury

A 34 year old woman with pulmonary tuberculosis started first-line anti-tuberculosis therapy comprising rifampicin, isoniazid, pyrazinamide, and ethambutol. Two weeks into treatment, she complained of nausea and dark discoloration of urine. Liver enzymes and bilirubin (normal at baseline) were raised, with levels of bilirubin three times above the upper limit of normal, alanine aminotransferase four times above, and alkaline phosphatase two times above. A diagnosis of anti-tuberculosis drug-induced liver injury (DILI) was made, and all her anti-tuberculosis drugs were stopped. Over a period of 10 days, her DILI related symptoms resolved and liverfunction tests normalised. Ethambutol and isoniazid were then restarted, followed three days later by the addition of rifampicin and, a further three days later, pyrazinamide. No recurrence of DILI was encountered, and the patient completed anti-tuberculosis therapy successfully.