LAUSR

With an increase of prescription medication and herbal supplemental use, drug induced liver injury (DILI) has become progressively a more important entity when considering acute hepatitis aetiology. The unpredictable fashion and low frequency of idiosyncratic DILI, along with the highly variable clinical scenerios it can assume, turns DILI into an under-recognised event. Therefore, clinical suspicion, thorough medical history and many a time confirmatory histology remain the most relevant clues for diagnosis and imputability. Tibolone is a synthetic oestrogen commonly used to minimize menopause symptoms. It is usually well tolerated and liver toxicity has been previously reported only in three occasions.1--3 The authors report a case of tibolone acute hepatitis with cytolytic pattern. A 45-year-old female was referred to the Hepatology Clinic because of abnormal liver function tests. She was asymptomatic and denied fever, rash, anorexia or malaise. The physical examination was unremarkable: no jaundice, no scratch lesions, liver and spleen were not palpable. She had no history of alcohol intake and denied over the counter use of drugs or herbal products. She also denied extramarital sexual contacts and recent travels abroad. In her medical history, she pointed out that due to menopausal symptoms, she had been prescribed, 6 months earlier, with tibolone 2.5 mg, which she has been taking regularly. Just before starting, she had a complete blood count and liver function tests with normal profile. She presented now with asymptomatic rise of ALT and AST (600 UI/mL and 280 UI/mL, respectively) and GGT of 400 UI/mL, with normal ALP. Coagulation tests were normal as bilirubin and lipid profile. Abdominal ultrasonography showed no hepatomegaly, biliary duct dilation or portal vein thrombosis. Serology for hepatitis A, B and C virus, Epstein--Barr virus, Herpes simplex virus and Cytomegalovirus yielded negative results. Also,