Aloe Vera-Induced Hepatotoxicity

Abstract

Introduction: Herbal supplementation has been widely used by the general population as a safe and natural alternative to medications. Aloe Vera has been used as a sunburn reliever, laxative and in anti-aging products. Many herbal supplements have been linked to cause acute liver injury. Case presentation: We present a 52 year old male with history of hypertriglyceridemia who presented to our emergency department with complains of epigastric pain for 2 weeks duration. The patient described the pain as an intermittent sharp pain, 8/10 intensity, worse with food intake and no radiation. The Patient denied fever, chills, nausea, vomiting, diarrhea, constipation, melena or dysuria. The patient denied alcohol intake, acetaminophen or NSAIDS use. On further questioning patient revealed taking Aloe Vera extract to help with his abdominal pain. On arrival at the emergency room, his vitals were stable and he was afebrile. Laboratory workup was significant for an ALT of 837, an AST of 928, an a ALP of 175, a total bilirubin 1.6. an INR of 1.0. and a Lipase 473. CT of the abdomen showed fatty infiltration without focal lesion in the liver, cholelithiasis, with normal sized common bile duct. No evidence of pancreatitis seen. Workup for liver disease including viral hepatitis, acetaminophen level, iron studies, ceruloplasmin, ANA, AMA, ASMA, LKM AB, immunoglobulins were all normal. The patient was advised to stop taking Aloe Vera and was monitored in the hospital for 2 days with resolution of his symptoms. On two months follow up, the patient was asymptomatic and his LFTs are back to normal limits. Discussion: Patients usually take herbal supplementation with assumption that it is safe. Without careful history taking, many patients won't admit to using herbal supplementation. Establishing a definitive causative relationship between herbal supplement and hepatotoxicity is very challenging as a re-challenge may be unethical. Using the Roussel Uclaf Causality Assessment Method for determining drug hepatotoxicity (RUCAM) scale our patient scored 8 points which placed Aloe-vera as a “probable” cause of hepatotoxicity in our patient\ Conclusion: Herbal supplementation should be considered and investigated in patients presenting with hepatotoxicity. Careful history taking may reveal otherwise hidden causes of acute hepatis.