Acute Liver Injury With Cholestatic Pattern: An Adverse Effect of Trimethoprim-Sulfamethoxazole

Trimethoprim-sulfamethoxazole (TMP-SMX), commonly known by the brand name Bactrim, is a combination antibiotic medication that is used to treat a broad spectrum of infections. It is known to be associated with a wide array of adverse reactions, including drug-induced liver injury (DILI). Drug-induced liver injury associated with TMP-SMX more commonly presents with a hepatocellular or mixed liver injury pattern rather than a cholestatic pattern. Here, we present the case of a 52-year-old female patient who presented with jaundice and pruritus after a recent course of TMP-SMX. Labs and imaging revealed cholestatic liver injury without obstruction. Further testing ruled out autoimmune and infectious causes. The patient's condition was resolved within five days of presentation with only supportive care administered. Given the clinical course as well as the exclusion of other likely causes, we concluded that this was a case of TMP-SMX-associated acute liver injury with a cholestatic pattern.