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Acute Liver Injury Following Outpatient Trimethoprim‐Sulfamethoxazole Use for Small Intestinal Bacterial Overgrowth: A Case Report
Journal article   Open access   Peer reviewed

Acute Liver Injury Following Outpatient Trimethoprim‐Sulfamethoxazole Use for Small Intestinal Bacterial Overgrowth: A Case Report

Kaylie Duit, Joseph Rattenni, Lauryn Hanson and Aaron R. Kunz
Clinical case reports, Vol.14(7), e72989
06/30/2026
DOI: 10.1002/ccr3.72989
PMID: 42389032
Appears in  UI Libraries Support Open Access
url
https://doi.org/10.1002/ccr3.72989View
Published (Version of record) Open Access

Abstract

Drug‐induced liver injury (DILI) is a leading cause of acute liver failure in the United States and remains difficult to predict and diagnose. Trimethoprim‐sulfamethoxazole (TMP‐SMX) is widely prescribed and generally well tolerated, yet rare cases of severe idiosyncratic hepatotoxicity have been reported. We describe a 30‐year‐old woman who developed fever, malaise, leukopenia, and profound hepatocellular injury days after initiating TMP‐SMX and neomycin for small intestinal bacterial overgrowth. TMP‐SMX was discontinued, and treatment with N‐acetylcysteine (NAC) and supportive care was initiated. Liver enzymes, coagulopathy, and renal dysfunction steadily improved, and the patient was discharged on hospital day 6 with complete resolution of laboratory abnormalities within one month. In addition to highlighting another documented case of liver injury caused by TMP‐SMX, this case emphasizes the unpredictable nature of drug‐induced hepatotoxicity, the potential use of NAC in DILI, and reinforces the importance of early recognition, comprehensive evaluation, and prompt withdrawal of the offending agent. Clinicians should maintain vigilance when new constitutional or hepatic symptoms arise during therapy and should report suspected cases to improve collective understanding and patient safety data. Clinicians should be aware of the potential for severe liver injury as a result of prescribing trimethoprim‐sulfamethoxazole. Review of reported cases involving trimethoprim‐sulfamethoxazole drug‐induced liver injury trends toward female susceptibility, with diversity in hepatocellular insult. Further studies are needed to explain variability in symptom onset, clinical course, and patient outcomes.
 chemical and drug induced liver injury drug-related side effects adverse reactions small intestinal bacterial overgrowth trimethoprim-sulfamethoxazole drug combination UIOWA OA Agreement

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