Cholestatic hepatitis: An unusual presentation of lisinopril induced hepatotoxicity

Previously published case reports have shown direct hepatocellular injury as the mechanism for lisinopril induced hepatotoxicity. We report case of a 47 year old female who presented with jaundice, diagnosed as cholestatic hepatitis; two years after initiation of lisinopril. Extensive work up was negative for other causes of hepatitis. Liver biopsy showed portal inflammation by lymphocytes without centrilobular necrosis, which is similar to earlier case reports. Discontinuation of angiotensin converting enzyme inhibitors (ACE-I) usually leads to normalization of liver enzymes, however continuation or re-initiation can be potentially fatal.

This is the first reported case of lisinopril induced hepatotoxicity via cholestatic mechanism. Some reports hypothesize a metabolic idiosyncratic reaction as the molecular mechanism but currently there is no validated literature. This case highlights the need for further research to explore mechanisms for ACE-I mediated hepatotoxicity and to create awareness amongst physicians to consider ACE-I as an etiology for drug induced liver injury.