TMP-SMX is frequently associated with cholestatic liver injury, which can be severe.2-4 This drug can interfere with normal hepatocyte secretion of bile constituents and typically produces jaundice without significant hepatitis, as seen in this patient. Acetaminophen, which can be highly toxic to the liver if taken in high doses, usually produces a severe drug-induced hepatitis, which this patient does not have. Sumatriptan is not strongly associated with liver disease. A HIDA scan would likely identify cholecystitis or obstructive jaundice from choledocholithiasis but was normal in this patient.
2. Kowdley KV, Keeffe EB, Fawaz KA. Prolonged cholestasis due to trimethoprim sulfamethoxazole. Gastroenterology 1992;102:2148-50.
3. Horák J, Mertl L, Hrabal P. Severe liver injuries due to sulfamethoxazole-
trimethoprim and sulfamethoxydiazine. Hepatogastroenterology 1984;31:199-200.
4. Abi-Mansur P, Ardiaca MC, Allam C, Shamma'a M. Trimethoprim-
sulfamethoxazole-induced cholestasis. Am J Gastroenterol 1981;76:356-9.
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