2419 Fatal Outcome Associated With Herbal Supplements

Abstract

INTRODUCTION: Herbal and dietary supplements are widely used without prescription and used by the public as harmless remedies for a variety of ailments. It is difficult to determine causal relationships between herbal preparations and hepatotoxicity. We present a case of fulminant hepatic failure from over-the-counter hair regrowth supplements containing Polygonum multiflorum. CASE DESCRIPTION/METHODS: A 71-year-old male presented to the ER with complaints of abdominal discomfort and jaundice, associated with nausea and vomiting. He went to the ER ten days prior for abdominal discomfort and nausea, labs showed total bilirubin 1.8, ALP 141, AST 267, ALT 85, platelet 70, BUN 31 and Creatinine 1.2. CT abdomen showed duodenitis and was discharged with Metoclopramide. His symptoms continued to worsen. 12 weeks prior, he started a hair regrowth supplement which contained Polygonum multiflorum. Pertinent labs were-Total Bilirubin 9.8, AP 280, AST 445, ALT 156, platelet 49, BUN 85, creatinine 3.4 and INR 1.82. CT abdomen showed mild hepatic steatosis, mild peripancreatic and periduodenal inflammatory changes. Ultrasound of the gallbladder showed no gallstones or cholecystitis. Normal CBD and common hepatic duct. Hepatitis A, B, C, Anti-smooth muscle antibodies, anti-mitochondrial antibodies, smear for parasites and tick borne were negative, IgG, IgM, IgA – normal, Ceruloplasmin 45. Acetaminophen level <10. He was getting supportive treatment. Day 3 labs showed AST 556, ALT 151, AP 278, total bilirubin 15.1, direct bilirubin 14.6, PT 23.7, INR 2.03. platelets 24, BUN 97, creatinine 2.5. He was started on Acetylcysteine and Lactulose, then transferred to a hospital with a liver transplant facility, where toxicology screening was positive for P multiflorum. He was not a candidate for liver transplant and labs continued to worsen. Shortly thereafter he coded while getting an HD catheter for dialysis and expired. Liver biopsy after autopsy showed diffuse necrosis of hepatic cells. DISCUSSION: The mechanism of hepatotoxicity of P multiflorum is unknown but it is known to have anthraquinones including chrysophanol, emodin, and rhein which can induce hepatotoxicity. The pattern of enzyme elevations is typically hepatocellular or mixed and the clinically resembles acute viral hepatitis. The latency to onset ranges from a few days to as long as 6 months. Liver biopsies show changes typical of acute hepatitis. The course is usually self-limited but there are also a small number of patients with liver failure and even death.