Autoimmune progesterone dermatitis as a clue to refractory jaundice in a young lady

A lady in her 20s presented to the emergency department with profound icterus which had not resolved with standard hepato-protective measures (ursodeoxycholic acid, cholestyramine, N-acetyl cysteine). She had nausea, malaise and intense pruritus all over the body. Drug history revealed the intake of progesterone (norethisterone acetate, 5mg/day) for menorrhagia one week prior to the development of the icterus. Blood investigations revealed raised total bilirubin=24.4mg/dL, (direct =23.9mg/dL) and serum alkaline phosphatase=206 IU/L, (44-147) with normal liver enzyme levels.