A Rare Case of Mango Tea-associated Hepatotoxicity

Abstract

Mango (Mangifera genus) fruit, pulp and seed kernel extract have been purported to be hepatoprotective.1 The tea is thought to help control pain. We report a rare case of mango tea induced acute liver injury which rapidly improved after cessation of use. A 53 year old Hispanic woman with history of dyspepsia presented with 1 day of epigastric pain not relieved by PPI and 1 month of anorexia and fatigue in the setting of abnormal liver tests. She reported drinking a glass of homemade mango tea, prepared by boiling the whole fruit, 3-5 times weekly for the past month. She also took Excedrin 1-2 times/week for occasional back pain. Her physical exam was significant for normal vital signs, mild epigastric and RUQ tenderness, no organomegaly, and no jaundice. Labs showed a hepatocellular pattern of injury: AST 2461, ALT 1626, ALK Phos 168 U/L, TB 1.7, DB 0.9 mg/dL, TP 7.8, ALB 3.5 g/dL, GGT 339, PT 10.6, and INR 1.01. Acetaminophen level was 20, EtOH level < 3, amylase 42, lipase 185, and LDH 1453. With cessation of mango tea and IVF hydration, hepatic panel trended down within 12 hours to: AST 776, ALT 1042, ALK P 163 U/L, TB 1.5, DB 1.0 mg/dL, TP 6.2, and ALB 3.0 g/dL. The patient became febrile on the day of admission with temperature of 101.7F. Evaluation for infections revealed negative viral serology for EBV, CMV, herpes, varicella, HBV and HCV with remote immunity to HAV. Anti-smooth muscle Ab and ANA titers were within normal limits. Abdominal ultrasound revealed normal liver size, homogeneous parenchyma, small mobile calculi in the gallbladder, and normal common bile duct. Abdominal CT showed unremarkable liver, spleen, gallbladder, and pancreas. MRCP showed unremarkable liver, mild cholelithiasis, and no biliary ductal dilatation or choledocholithiasis. Liver enzymes continued to trend down and the patient was discharged. On follow up, 16 days after presentation, hepatic panel had returned to within normal limits: AST 26, ALT 41, ALK P 109 U/L, TB 0.5, DB 0.1 mg/dL, TP 7.2, and ALB 4.2 g/dL (Figure 1). We posit ingestion of large amounts of mango tea induced acute hepatocellular injury in our patient. RUCAM/CIOMS score for herb induced liver injury causality was 7 (probable). This is contrary to current literature.1 (1. Antioxidant and hepatoprotective activities of thai mango seed kernel extract. Nithitanakool S et al. Planta Med. 2009; 75(10):1118-23) Patients must be careful in their use of natural teas.FigureTable: Table. RUCAM/CIOMS Score