Case presentation

A 47-year-old African female with no prior medical history was prescribed amoxicillin 1.5 gram per day in three divided doses for acute upper respiratory tract infection. She responded well, but eighteen days later she reported fever, a skin rash on her limbs and trunk, widespread body itching, yellowish discoloration of the eyes, and abdominal pain marked on the left upper region. Physical examination was notable for fever, sclera jaundice, facial edema, diffuse erythema and scaling involving the trunk, limbs and the face (Figure 1A). The oral mucosa lining was intact. There was tenderness on left hypochondriac, and the liver span was within the normal limit. Laboratory test results revealed elevated serum alkaline phosphatase (233 U/L), moderately elevated transaminases: keeping with a mixed pattern of liver injury. conjugated bilirubin (81 µmol/L), alkaline phosphatase (470 U/L), creatinine kinase (23 ng/mL) was also elevated. Peripheral eosinophils count (0.01 x 109/L) was within the normal limit. Further testing dismissed evidence of metabolic, autoimmune, or infectious causes of liver injury. A Computed tomography and Magnetic resonance imaging showed no structural abnormalities on the liver, gallbladder, pancreas or bile ducts except for left anterolateral abdominal wall thickening without intramuscular collection. A skin biopsy revealed dermal pigment incontinence and localized inflammation with lymphocytic predominance. Similarly, a liver biopsy indicated bile accumulation in centrilobular hepatocytes and Kupffer cells, as well as inflammatory infiltrates predominantly of lymphocytes and eosinophils