A case of hepatic injury suspected to be caused by Canephron N, a Centaurium Hill containing phytotherapeutics

Abstract

Drug induced liver impairment causes 2–5% of hospitalizations in patients with jaundice and 10–20% of cases of fulminant hepatic failure [1]. Herbal medicines are the cause of drug induced liver impairment in only 2% of patients [2]. But due to wide use of such medications, especially for self-treatment, they may be a clinically significant cause of hepatotoxicity [3]. In this article, we describe a case of drug induced hepatic injury presumably caused by use of a medication containing extracts of Centaurium Hill herb, Lovage root, and Rosmarinus leaves (other ingredients: Corn starch, colloid silicon dioxide, lactose monohydrate, poly(1-vinyl-2-pyrrolidone), magnesium stearate, red ferric oxide (E172), riboflavin E101, calcium carbonate, dextrose, modified corn starch, glycol mineral wax, castor oil, sucrose, shellac, talc, titanium dioxide). A 66-years-old woman, employed as a research officer, is admitted to internal medicine unit with jaundice of skin, mucosa, and sclera. The patient was diagnosed with schizophrenia after a psychotic episode in 2007 and is since taking risperidone and clomipramine. She is under a surveillance of a psychiatrist and her physician observed no relapse of psychosis. She has not had viral hepatitis, she also denies having any alcohol or illicit drug abuse. Otherwise her medical history is unremarkable. Two weeks before hospitalization she noticed baggy skin below the eyes, her urination became more frequent, but remained painless and without hematuria. For this she attended her primary care physician who after having diagnosed cystitis prescribed Canephron N (Bionorica AG, Germany, http:// www.bionorica.de/cda/produkte auf einen blick/canephron n/content-128906.html) containing extracts from Centaurium (Centaurium umbellatum), Lovage (Levisticum officinale) and Rosmarinus (Rosmarinus officinale) at a dose of 2 dragee three times a day for two weeks. After 1 week of treatment the patient noticed jaundice on sclera, then on skin. Jaundice was increasing in intensity, but the patient did not experience any other symptoms. Two days before admission she has a biochemistry panel made which revealed high bilirubine 369,2 mcmol/l (reference range 9–25 mcmol/l), direct bilirubine – 284,5 mcmol/l, ALT (SGPT) 302 EU/L (reference range 0–40), AST (SGOT) 89 EU/L (reference range 0–40), GGT 456