Cloxacillin- and Terbinafine-Associated Mixed Drug-Induced Liver Injury: Contrasting Clinical Outcomes and Causality Assessment Using the Updated RUCAM

Background

Idiosyncratic drug-induced liver injury (DILI) is an uncommon but potentially severe adverse drug reaction. Although cloxacillin and terbinafine are long-established, widely prescribed agents, both have been associated with mixed/cholestatic DILI, occasionally resulting in prolonged cholestasis or vanishing bile duct syndrome (VBDS). We report two cases with similar clinical and biochemical presentations but markedly different histological findings and long-term outcomes, illustrating that the initial biochemical phenotype may not reflect the extent of bile duct injury or predict subsequent clinical evolution.