2421 A Case of Acute Liver Injury Caused by an Herbal Supplement Containing Saw Palmetto: “Good for the Prostate but Not for the Liver”

Abstract

INTRODUCTION: Saw palmetto (Serenoa repens), an herbal product used for benign prostatic hyperplasia, is a part of many herbal and dietary supplements (HDS) used for bodybuilding. It is associated with a hepatocellular pattern of acute liver injury. We present a case of liver injury secondary to supplement containing saw palmetto, which improved upon discontinuation. CASE DESCRIPTION/METHODS: A 36-year-old man with history of gastric bypass surgery was admitted with vomiting and diarrhea for the last 2 days. Abdominal examination was unremarkable. Labs revealed ALT of 2200 U/L, AST of 800 U/L with normal bilirubin, alkaline phosphatase and INR. Abdominal ultrasound revealed gallstones with a normal bile duct. Work up for infectious diarrhea was unremarkable. The symptoms were attributed to acute viral gastroenteritis. A diagnosis of acute liver injury was made, and further tests were performed to establish the etiology. Viral markers for Hepatitis A, B, C, E, Epstein Barr, Herpes simplex and Cytomegalovirus were all negative. The ANA, ASMA, ceruloplasmin and acetaminophen levels were unremarkable. He denied any alcohol use. Further history revealed that he had been using an over the counter herbal product to boost the testosterone levels to increase the muscle mass for the last one month. The ingredients of the product included saw palmetto and other herbal constituents. Review of the literature showed an association between saw palmetto and hepatocellular type of liver injury. The liver injury was attributed to the supplement and the cessation was advised. Follow up 4 weeks later showed normalization of the liver profile. DISCUSSION: HDS induced liver injury accounts for 20% cases of hepatotoxicity and 13% cases of acute liver failure in America. Many such cases are due to MINS (multi ingredient nutritional supplements), and the component responsible for the toxicity is usually unknown or can only be suspected. One of such ingredients used in these products is sawPalmetto which may cause supplement-induced liver injury. The latency to onset is within 1 to 2 weeks, and the clinical features resemble acute viral hepatitis with a hepatocellular pattern of liver enzyme elevations. Liver injury is probably an idiosyncratic phenomenon and usually resolves in 1 to 3 months. HDS-induced liver injury presents many challenges in diagnosis, identification of the responsible constituents, treatment and prevention. The regulation of non-prescription products to guarantee public safety is very important.