Allopurinol-Induced Granulomatous Hepatitis: A Case Report and Review of Literature

Liver enzyme elevation is a common reason for referral to a gastroenterologist. Drugs are one of the most common reasons for asymptomatic elevation of liver enzymes. We present here a case of granulomatous hepatitis (GH) secondary to long-term use of allopurinol. An 83-year-old male with a history of chronic gout and hypertension was evaluated for elevation of liver enzymes. He denies any complaints of abdominal pain, nausea, fever, chills, weight loss, night sweats, or yellowness of skin. He denies any use of herbal medications. He was on losartan and allopurinol for years. No new medications reported. Physical examination was unremarkable. Labs showed aspartate transaminase 101 U/L, alanine transaminase 81 U/L, and alkaline phosphatase 645 U/L. Ultrasound of the abdomen showed coarse liver texture. Liver biopsy was done that showed mixed GH. Given negative autoimmune and viral serologies, allopurinol-induced GH was suspected. Allopurinol was held, and repeat liver enzymes were checked in 3 months, which showed improvement in transaminase and alkaline phosphatase levels. This case highlights the importance of reviewing medications carefully when evaluating a patient with liver enzymes elevation, as stopping the offending drug can normalize the abnormalities in liver chemistries and can prevent subsequent expensive testing.