Acute Liver Injury Related to Ingestion Jamaican National Fruit (Ackee Fruit)

Abstract

Drug or Toxin induced liver injury can present as hepatocellular and/or cholestatic hepatitis and the course of the disease can be from acute liver injury to fulminant liver failure resulting in death or required orthotopic liver transplantation. We present a case of acute subfulminant liver injury from ingestion of Ackee fruit which is a member of the Sapindaceae and it is a native fruit to Jamaica and some parts of West Africa. 42-year-old Jamaican woman with postpartum hypertension had undergone an unremarkable pregnancy and delivery 5 months prior. She presented with dark urine, jaundice, malaise for 2 weeks and one episode vomiting on the day of admission. She was afebrile. She was taking Enalapril 2.5mg daily and labetatol 100mg TID. No history of alcohol, Tylenol or liver disease. Labs revealed AST/ALT 1239/1551 U/L and bilirubin 11.3 mg/dl. Extensive serologic workup was negative for viral, metabolic and autoimmune with exception for positive antibody to mitochondria. Imagings ruled out common bile duct obstruction and ascites. Liver biopsy showed subfulminant hepatitis with lobular, interface and piecemeal necrosis. Amlodipine 5mg was started for hypertension on discharge. At 2 week follow up, her bilirubin increased to 20.1 and AST/ALT 1148/869. Vitals remained stable with no confusion. Obtaining detailed history, it was found that she had eaten Ackee fruit which had been brought by her relatives from Jamaica two weeks before her initial admission. She continued to have Ackee dish even after the first hospital discharge. Repeat liver biopsy showed mild steatosis, bridging and centrilobular necrosis with rare eosinophils(Fig 1). She was instructed to avoid Ackee on discharge and her results became normal after 3 months.Figure 1The toxicity of Ackee is hypoglycin A and B. Hypoglycin A is translocated from aril to the seeds of the fruit during maturity(Fig 2) resulting in impaired gluconeogenesis and beta oxidation of fatty acid in mitochondria. Studies mentioned toxicity due to Enalapirl appeared at daily dose of 20mg or more. Thorough history taking is crucial in patients presenting with liver injury. To the best of our knowledge, this is the first case of acute subfulminant liver injury related to ingestion of Ackee fruit in a healthy middle age woman who subsequently had complete recovery with no liver transplantation after withdrawal of the offending agent. The importation of ackee is prohibited in the United States and only canned fruit is available.Figure 2