Background: Cocaine-induced toxicity has been described to be associated with severe adverse clinical health outcomes, affecting multiple organs systems with very limited clinical recommendations or guidelines for management of some of its associated complications. Case report:We present a case of middle-aged female with acute severe hepatotoxicity after ingestion of alcohol and non-intravenous cocaine. She had markedly elevated liver enzymes and lactate dehydrogenase suggestive of shock liver but with minimal overt systemic manifestations. Patient was managed conservatively with intravenous fluids and treatment of con-current co-morbidities and liver enzymes and lactate dehydrogenase declined rapidly over a 5-day hospital course. Discussion:We hypothesize that cocaine may play a role in diminishing hepatic perfusion, mimicking an ischemic hepatitis type clinical presentation and suggest that similar management, based on volume resuscitation, will potentially be more helpful than harmful for patient's presenting with acute cocaine-induced liver injury.