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