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J Clin Pathol 62:481-492 doi:10.1136/jcp.2008.058248
  • Review

Histological patterns in drug-induced liver disease

Table 2 Overview of drug-induced liver injury patterns
Histological pattern Differential diagnosis Common drugs involved
Acute hepatitis and cholestatic hepatitis Viral hepatitis, autoimmune hepatitis, Wilson disease, idiopathic See table 3
Acute liver failure
    Necrosis with marked inflammation Autoimmune hepatitis, viral hepatitis, Wilson disease Isoniazid, monoamine oxidase inhibitors, anticonvulsants (phenytoin, valproate), antimicrobials (sulfonamides, cotrimoxazole, ketoconazole)
    Necrosis with little or no inflammation Herpes simplex or adenoviral hepatitis, Wilson disease, malignant infiltration Acetaminophen, cocaine, MDMA (ecstasy), carbon tetrachloride
    Microvesicular steatosis with little or no inflammation Acute alcohol intoxication, Reye syndrome, fatty liver of pregnancy Tetracycline, nucleoside analogues
Chronic hepatitis
    Autoimmune marker-negative Autoimmune hepatitis. chronic viral hepatitis, Wilson disease Lisinopril, sulfonamides, trazodone, uracil, tegafur, tamoxifen, methotrexate
    Drug-induced autoimmune hepatitis Autoimmune hepatitis Minocycline, nitrofurantoin, methyldopa, clometacin
Cholestasis
    Bland cholestasis Sepsis, cardiac failure, shock, large duct obstruction, benign intrahepatic cholestasis, intrahepatic cholestasis of pregnancy Anabolic/androgenic steroids, oestrogenic steroids, NSAIDs (nimesulide, piroxicam)
    Cholestatic hepatitis (cholangiolitic or hypersensitivity cholestasis) Viral hepatitis, large duct obstruction Chlorpromazine, clarithromycin
Granulomatous hepatitis Infections, sarcoidosis, primary biliary cirrhosis, talc, metal toxicity Isoniazid, interferon, phenytoin, allopurinol (also see box 2)
Steatosis/steatohepatitis
    Macrovesicular steatosis Diabetes, obesity, Wilson disease, hepatitis C Alcohol, steroids, total parenteral nutrition, gold, chlorinated hydrocarbons, chemotherapeutic agents (5-fluorouracil)
    Microvesicular steatosis Fatty liver of pregnancy, carnitine deficiency, Reye syndrome Cocaine, tetracycline, valproic acid, zidovudine
    Steatohepatitis (See macrovesicular steatosis differential) Amiodarone, chemotherapeutic agents (irinotecan), perhexiline
Vascular abnormalities
    Sinusoidal obstruction syndrome Myeloablation, venous outflow obstruction, right heart disease Oxaliplatin, pyrrolizidine alkaloids, chemotherapy for ALL
  • ALL, acute lymphoblastic leukaemia; MDMA, 3,4-methylenedioxymethylamphetamine; NSAID, non-steroidal anti-inflammatory drug.

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