Azathioprine-induced cholestatic hepatic toxicity in pregnancy with lupus nephritis

Azathioprine is commonly used in the management of lupus nephritis and is considered relatively safe during pregnancy. However, rare hepatic adverse effects, including cholestatic liver injury, have been reported. This case is presented to highlight an uncommon occurrence of azathioprine-induced cholestatic hepatotoxicity during pregnancy and the diagnostic challenge in distinguishing it from intrahepatic cholestasis of pregnancy. A 23-yearold primigravida with lupus nephritis, who had been receiving azathioprine since December 2023, presented at 22 weeks of gestation with jaundice, steatorrhoea, and dark-colored urine. Extensive evaluation excluded viral, autoimmune, metabolic, and obstructive liver diseases. Withdrawal of azathioprine and initiation of ursodeoxycholic acid resulted in marked biochemical improvement. This case emphasises the importance of recognising drug-induced cholestasis in pregnant women receiving azathioprine and the value of regular hepatic monitoring to ensure favourable maternal outcomes.