Diagnosis, Management, and Outcome of Antituberculous Drug-Induced Liver Injury in a Low-Resource Setting: A Case...

Antituberculous drugs carry substantial hepatotoxic risk, most commonly manifesting as idiosyncratic drug-induced liver injury. Although cases of antituberculosis drug-induced liver injury (AT-DILI) have been reported in Ghana, significant challenges remain in its diagnosis, monitoring, and management in low-resource settings.

We report the case of a 50-year-old woman who developed severe AT-DILI, initially misdiagnosed as cholecystitis, on a background of chronic hepatitis C infection with established liver cirrhosis. She was referred to the Tamale Teaching Hospital during the continuation phase of first-line antituberculosis therapy, presenting with nausea, anorexia, and right upper quadrant abdominal pain. A clinical examination revealed mild pallor, jaundice, Grade 1 bilateral pitting pedal edema, and moderate ascites.

At the referral facility, diagnostic and monitoring constraints were encountered, including the unavailability of liver biopsy, the lack of routine baseline liver function testing, and out-of-pocket costs for serial laboratory monitoring. In addition, the absence of single-drug formulations of isoniazid and rifampicin precluded sequential rechallenges, necessitating rechallenges with a fixed-dose combination during the continuation phase. The patient failed rechallenge and was transitioned to an all-oral second-line antituberculous regimen consisting of bedaquiline, pretomanid, linezolid, and moxifloxacin, alongside direct-acting antiviral therapy for chronic hepatitis C. This resulted in the resolution of liver injury and the successful completion of tuberculosis treatment without complications.

This case highlights the diagnostic and management challenges of AT-DILI in low-resource settings, particularly where baseline liver function testing, serial monitoring, and access to single-drug formulations for rechallenge are limited.