Acute Liver Failure Following a Year of Consumption of a Popular Sugar-free Energy Drink

Abstract

Purpose: A 36-year-old Caucasian male without prior medical history initially presented to another facility with one week of right upper quadrant (RUQ) abdominal pain, jaundice and fatigue. After abnormal lab values (Table 1) were found, he left that facility and presented to this hospital. He admitted to weekend binge drinking and drank 10 beers three hours prior to symptom onset. He denied taking herbal remedies, homeopathic medications or other supplements. He drank up to three energy drinks (Figure 1) on a daily basis for the past year. Physical exam showed stable vital signs, jaundice, spider nevi and RUQ tenderness. Initial work-up was negative for viral, ischemic or autoimmune hepatitis. On HD #6, a liver biopsy showed severe active hepatitis with bridging necrosis consistent with an herbal/drug-toxicity pattern. On HD #9, the patient was discharged home, but was soon re-admitted for worsening LFTs. With an INR of 4.2, he was placed on the UNOS waiting list with a MELD score of 41. On HD #14 of this secondhospitalization, a suitable donor became available and the patient underwent successful liver transplantation. Gross liver pathology showed massive hepatocellular necrosis and parenchymal collapse consistent with drug-induced liver injury. He was discharged on post-operative day number seven.Table 1: Laboratory findingsFigure 1: Ingredients of sugar-free energy drink.Discussion: A similar case report by Vivekanandarajah et al. described a young woman who drank 10 cans of an energy drink for 2 weeks, resulting in acute hepatitis. The authors concluded that Vitamin B3 (niacin) was the culprit ingredient. Our case report details a patient who drank a sugar-free energy drink over a longer period and had a more serious clinical course. The patient's prior alcohol use may have provided a “first hit” on the liver, making it more susceptible to further insults. The energy drink in this case report contains many ingredients, some of which do not have a well-established safety profile. While drinking modest amounts of energy drinks appears to be relatively safe, frequent consumption over an extended period of time has recently been linked with hepatic injury.