The University of Toledo Translation Journal of Medical Sciences 
Gastroenterology Abstract, Department of Medicine Research Symposium UTJMS 2023 May 05; 11(1):e1-e1 

Severe Transaminitis in Allopurinol-Induced DILI 
presenting as DRESS Syndrome 
Dhanushya Battepati1*, Daniel O’Shea1, Brandon Speedy1, David Farrow, MD2, 
Megan Karrick, DO1, Anas Renno, MD1, Mona Hassan, MD1

1Division of Gastroenterology and Hepatology, Department of Medicine, The 
University of Toledo, Toledo, OH 43614 
2Division of Internal Medicine, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 

*Corresponding author: Dhanushya.Battepati@rockets.utoledo.edu

Published: 05 May 2023 

Introduction:  Patient is an 81-year-old male who presented for significant dyspnea and rash. Further 
workup demonstrated morbilliform rash, severe transaminitis, elevated alkaline phosphatase, acute 
kidney injury, and mild eosinophilia. 

Case Description: Four weeks prior to admission, the patient was placed on allopurinol for acute gouty 
arthritis and developed the erythematous, pruritic rash shortly before admission. The rash presented over 
the trunk and bilateral upper and lower extremities. Patient was given betamethasone cream and 
Benadryl three times daily with no relief.  Upon cessation of allopurinol and initiation of high-dose 
corticosteroids in the hospital, the transaminitis began resolving within two days and the rash stabilized.  

Discussion: We reviewed the PubMed database to identify cases of allopurinol-induced drug-induced 
liver injury. The patient’s LFTs, especially ALT, were significantly higher than the LFTs in a previous 
case series (median ALT: 500s). This patient’s ALT peaked at 1818 U/L, while AST (278) and Alk Phos 
(339) were also elevated. Liver injury pattern in drug reaction with eosinophilia and systemic symptoms 
(DRESS) is either cholestatic or hepatocellular. The patient we present demonstrates a hepatocellular 
pattern of liver injury. In a case series of 16 patients with DRESS and acute liver injury, six patients 
underwent emergency liver transplantation. It is extremely important to closely monitor LFTs and 
determine the grade of severity as acute liver failure may manifest, although rare. Overall, this patient 
presented with severe allopurinol-induced drug-induced liver injury (DILI) with Grade 4 AIDS CTG 
criteria ALT and AST elevations.

https://dx.doi.org/10.46570/utjms.vol11-2023-657 

https://dx.doi.org/10.46570/utjms.vol11-2023-657
mailto:Dhanushya.Battepati@rockets.utoledo.edu