ArticleFrontiers in medicine2026
Case Report: Persistent indirect hyperbilirubinemia caused by Gilbert syndrome misdiagnosed as drug-induced liver injury during tuberculosis treatment.
Article in Frontiers in medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: Drug-induced liver injury (DILI) is a common complication of anti-tuberculosis therapy and frequently leads to treatment interruption or modification. In routine clinical practice, liver function abnormalities during tuberculosis treatment are often attributed to DILI. However, isolated indirect hyperbilirubinemia in the presence of persistently normal transaminase levels represents an atypical biochemical pattern that is inconsistent with classical hepatocellular injury and may indicate alternative underlying conditions, posing a diagnostic challenge in tuberculosis management. Case presentation: We report the case of a 22-year-old Han Chinese woman treated for smear-negative pulmonary tuberculosis who developed recurrent elevations in total and indirect bilirubin while alanine aminotransferase and aspartate aminotransferase levels remained persistently within normal ranges. These abnormalities were repeatedly misinterpreted as suspected DILI, resulting in multiple interruptions and modifications of anti-tuberculosis regimens. Bilirubin levels continued to fluctuate despite drug withdrawal, suggesting a non-hepatocellular etiology. Repeated treatment interruption contributed to a delay in effective tuberculosis management exceeding 1 year and was associated with radiological disease progression and cavity formation. Management and outcome: Further evaluation, including Conclusion: This case highlights an important diagnostic pitfall during tuberculosis treatment. Persistent indirect hyperbilirubinemia with normal transaminases should prompt consideration of Gilbert syndrome rather than DILI. Early recognition and appropriate genetic testing may prevent unwarranted treatment interruption, reduce the risk of disease progression, and improve treatment continuity. To our knowledge, reports describing Gilbert syndrome masquerading as recurrent suspected DILI during tuberculosis treatment remain exceedingly rare.
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