INTRODUCTION: There are many well-known etiologies of acute liver failure. In the United States, DILI is the most common cause of fulminant hepatic failure1. Fluconazole is an antifungal medication that is frequently prescribed in the outpatient setting. Common side effects include vomiting, diarrhea, and headache. Here, we present a rare case of fluconazole induced acute liver failure. CASE DESCRIPTION/METHODS: An 80-year-old male with a history of prostate cancer presented to his PCP with complaints of worsening fatigue for several days. He had associated symptoms of fevers, decreased appetite, weight loss, and dark urine. His PCP, who noted his LFTs to be abnormal (Table 1), advised him to seek medical attention. On arrival to the ED, the patient reported having "sensitivity" in his hands and fingers for two months prior to arrival. He was seen by his dermatologist, who prescribed him Fluconazole 200 mg weekly. The medication was stopped after three doses due to development of a rash on bilateral hands and trunk, with the last dose being one-week prior to arrival. A thorough evaluation to exclude other causes was performed. Imaging demonstrated benign hepatic cysts largest measuring 3 cm but no findings of chronic liver disease. Over his hospital course, his condition worsened with the development of hepatic encephalopathy requiring intubation, coagulopathy, and acute renal failure (fulminant liver failure). Figure 1 demonstrates the trend in liver enzymes over the hospital stay. He was not a candidate for liver transplantation due to active cancer. Ultimately, his family withdrew support, and the patient passed away. DISCUSSION: Azole antifungal induced liver injury is largely asymptomatic and associated with mild LFT elevation. Overt liver failure and death occurs in less than 1% of this population2,3. One study found that users of fluconazole with a history of chronic liver disease had higher rates of severe acute liver injury than users of azole drugs without underlying chronic liver disease4. Few cases of fulminant liver failure in patients without underlying liver disease have been reported. Fluconazole is a commonly prescribed medication. It is important to be aware of the risk of liver injury in patients on antifungal azole medications. Further investigation is needed to ascertain the correlation of liver toxicity of fluconazole in patients without underlying liver disease.Figure 1.: Linear depiction of our patient's liver enzymes during hospitalization.Table 1.: Comprehensive metabolic panel on patient's admission.Table 2.: Coagulation studies on admission and nine days following admission.