Lisinopril-Induced Liver Injury: An Unusual Presentation and Literature Review

Abstract

Lisinopril is an angiotensin converting enzyme inhibitor (ACE-I) that has been on market for more than 25 years. ACE-I are usually well tolerated and rarely have serious or life-threatening side effects. We describe an unusual presentation of fulminant hepatic cholestasis probably secondary to lisinopril. To our knowledge, this is the second case report which shows lisinopril-induced liver injury though a cholestatic mechanism. The patient was a 59-year-old woman with type 2 diabetes, a high body mass index and hypertension, who presented with a 5-week history of jaundice and itching. She had been started on lisinopril for diabetic nephropathy 8 weeks before admission. Other causes for cholestasis had been excluded through non-invasive immunology and virology screening, an ultrasound of the liver, magnetic resonance cholangiopancreatography and a liver biopsy. The biopsy was consistent with drug-induced liver injury. Lisinopril was stopped 2 weeks before admission. The patient’s hospital stay was complicated by contrast nephropathy and influenza A which were both treated appropriately. Unfortunately, the liver cholestasis did not completely resolve following withdrawal of lisinopril and the patient died after 4 months. A literature search yielded only six other reported cases of lisinopril-induced liver injury. Five cases described hepatocellular damage and one showed cholestatic injury.

Delayed drug-induced liver injury (DILI) and flare of chronic plaque psoriasis secondary to lisinopril use

“…Although generally well tolerated, in very rare cases, ACEis have been associated with cholestatic jaundice and hepatitis with risk of progression to fulminant hepatic necrosis and hepatic failure 2. Limited previous case reports have varied in time from lisinopril initiation to drug-induced liver injury (DILI), from 12 days to 8 months 3. ACEis have also been associated with first presentation and exacerbation of psoriasis 4…”