An elderly female, with a definitive diagnosis of temporal arteritis which was under treatment, referred to our hospital with weakness, epigastric pain along with oral ulcerations. Before admission, the patient had developed right sided throbbing headache along with decrease in vision of her right eye with an ESR of 72 mm/h. She was diagnosed as having temporal arteritis and was administered steroids and azathioprine. After a couple of months, patient started having generalized weakness, epigastric pain and oral ulceration and then her intake of solid food decreased. Patient was kept on liquid diet that was delivered by a nasogastric tube. Upper GI endoscopy along with biopsy revealed cytomegalovirus (CMV) duodenitis. She was started on oral ganciclovir and later her symptoms improved.

Introduction: Drug induced liver injury post liver transplantation occurs in 1.7% of the patients. Tacrolimus being an effective immunosuppressant is used to treat acute rejection. However, it rarely can cause toxicity which is demonstrated by cholestatic liver injury. We hereby present the case of a young male, who was a diagnosed case of Wilson's disease, on pencillamine chelating therapy and underwent living related liver transplantation. Case: Within a month post transplantation he developed deranged, predominantly cholestatic pattern liver function tests. Laboratory parameters showed Total bilirubin 1.12mg/dl, ALT 553 IU/L Gamma-glutamyl transferase 624 IU/L and Tacrolimus level of 10.2ng/ml. After thorough evaluation liver biopsy was performed. Liver biopsy documented hepatocellular necrosis with centrilobular cholestasis without any evidence of graft rejection. Although with normal level of Tacrolimus, biopsy was suggestive of drug induced liver injury. Thus, Tacrolimus dose was reduced, which resulted in improvement of his LFTs and was later discharged. Conclusion/ Discussion: We have demonstrated tacrolimus induced toxicity in liver transplant recipients, despite normal serum levels. Thus, transplant physicians should keep high index of suspicion regarding toxicity in posttransplant setting. Tacrolimus is an effective post liver transplantation immunosuppressant and has the ability to treat early acute rejection. Liver biopsy documented hepatocellular necrosis with centrilobular cholestasis without any evidence of graft rejection. Cholestatic liver injury after tacrolimus usually resolves after dose reduction or by switching to another agent.

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