Does this sound like a DILI?
History of erythromycin use sine Christmas 2022 to control rosacea but altho a GP herself my daughter didnt follow the rules and stopped and started, also increasing and decreasing dose acc to how bad her rosacea was. On June 30th 2023 half an hour after going to bed absolutely fine, she had sever abdominal pain around and above belly button together with pain going thro to back and a squeezing sensation. Lasted maybe an hour, then pain went but squeezing continued the next day with slight nausea and fatigue altho not incapacitating as she managed to do a clinic. Following day on getting up noticed eyes slightly jaundiced and dark urine. Her GP sent her to the hospital for blood tests and her ALT was over 800. Alk Phos raised but nowhere near as much also bilirubin.
Follow up scans in hospital to look for gallstones all totally normal as were all other blood tests. Over next few days ALT rose steadily to peak at just under 1500. The jaundice became more generalised and the dark wee took a week to go, one day of pale stools, some itching, and then after about 5 days a weird triangular symmetrical red rash between the breasts which took a week to fade. After the third day she felt fine and could eat altho rather afraid to, but very tired.
Over next 10 days ALT dropped and in absence of anything else the Registrar sain his best guess was reaction to Erythromycin.
Over next 2 months she was fine, if a bit worried, and then in early September was booked to go to the world cup rugby in with her brother and 2 19 year old nephews. That same week her ALT reached 24, so she drank beer on 2 evenings before France to make sure she could, having had zero alcohol since that first episode in June. The game was on the Sunday and over the course of that day she drank 4 pints of beer which is a lot for her in normal cicumstances. Walking back from game she had some pain in URQ similar to June, but it passed after 30 mins of walking back to hotel and no other symptoms. 5 days later one of the nephews was off to uni so she joined the family for a heavy large evening meal with a further glass of wine, and was uncomfortably full but no pain. 48 hours later whilst driving she noticed the same pain again but it wasnt sever and passed after 20 mins. but she thought her urine was a bit orange that night, so returned to GP for LFTs and ALT up to 450ish. No other symptoms and the levels quickly dropped to normal over next 3 weeks.
She was referred to the Consultant this time and nearly missed the appt as she had caught a vomiting bug from one of her young patients, and was ill the previous night with slight fever. However she went, but he seemed to have decided that she probably had Sphincter of oddi even though her MRCP wsa normal and her pain not long lasting or really severe. She raised the DILI theory but he said it was unlikely because drug related causes typically presented with little or no pain. That is totally the opposite of everything we have read about erythromycin and liver injury, where severe pain is listed as the top symptom. Also she had that much milder episode in France where no drug was implicated, but I feel that maybe the alcohol that day may have upset a liver which wasnt fully recovered, and certainly that episode was nothing like the massive acute one back in June.
More bloods were done following the Consultant appt, and 3 weeks later when he finally sent her the results it appeared her Alt had gone up to 248. This was a total shock as she had had only fleeting pain which she thought might have been the aftermath of the vomiting bug, and it passed quite quickly, also was much lower in the abdomen, more like gas. No other symptoms at all. So she went back to her GP to get the ALT done again, and thankfully it had reverted to 33 after 3 weeks, which is normal tho maybe slightly high for her. Once again, no direct involvement for Erythromycin, but now I wonder if maybe having that winter vomiting bug just a few days before the bloodtest might have had an effect, especially if her liver is still on its way to recovery.
So my questions are, 1, is it possible after a severe episode and an ALT of 1500 for a liver to recover well, but still be fragile, so that alcohol could cause a much slighter relapse, and 2, if that is possible, could a tummy virus also send the ALT temporarily up though to a very much lesser degree ? How long after a severe DILI might it take for a liver to completely heal, and could the healing process still be going on even after the blood tests have returned to normal levels, during which time something could upset it?
I would be grateful for any input as the Consultant clearly thought the severe pain she had with the first episode in June ruled out a drug induced injury.
Elevated liver wnzymes
High Bilirubin 1.9 and 0.5
Fibroscan result/advice!
Alcohol withdrawal symptoms - itchy all over 
Depressed with confusing diagnosis!!
