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

Background: 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. Main Symptoms and Clinical Findings: 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. Diagnosis Therapeutic Intervention and Outcome: 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. Conclusion: 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.