Death from Herbal Tea: Hepatic Veno-occlusive Disease and Fulminant Hepatic Failure Secondary to Chinese Herbal Tea Ingestion

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Purpose: Veno-occlusive disease (VOD) is marked by a toxic injury to the hepatic sinusoids resulting in noncirrhotic portal hypertension. The course is typically self limiting, although up to 25% can progress to fulminant hepatic failure. Multiple potential etiologies for VOD have been described. Pyrrolizidine alkaloids, which can be found in herbal supplements, have been rarely associated with VOD. Shen Chu Cha, a supplement containing multiple herbs, is considered safe and is without known toxic effects. We present the first known case of VOD complicated by hepatic failure and death associated with Shen Chu Cha consumption. Results: A 63-year-old man presented for evaluation of an enlarging abdomen. He was on no prescribed medications and had no known allergies. He reported daily Shen Chu Cha tea consumption for general good health. His exam was significant for ascites and peripheral edema without stigmata of chronic liver disease. Initial labs showed AST 155, ALT 127, alkaline phosphatase 188, bilirubin 1.6 and INR of 1.73. Serology was negative for viral and autoimmune hepatitis, Wilson's disease and hemochromatosis. An ultrasound showed a normal appearing liver, ascites, and a patent portovenous system without intra or extra hepatic biliary dilatation. A paracentesis revealed portal hypertensive ascites. A liver biopsy was consistent with acute centrilobular necrosis, without inflammation or fibrosis. An hepatic venogram demonstrated a portal pressure gradient of >30 mmHgb, without evidence of Budd-Chiari syndrome. The diagnosis of VOD was confirmed. Diuretic therapy was administered with initial clinical response. However, the patient's medical condition deteriorated with development of hepatic failure. He subsequently died prior to organ transplantation. Conclusion: Shen Chu Cha, a supplement often self-prescribed for general good health, contains multiple herbs which are not associated with hepatic toxicity. One of the ingredients is the root of Baikal skullcap. Skullcap (Scutellaria baicalensis) has been considered safe. However, skullcap harvests are often contaminated with germander. Germander contains Teucrin A, a pyrrolizidine alkaloid. This case illustrates the importance of a detailed pharmacologic history, including herbal remedies. The toxic effects of herbal supplements are frequently unexpected and under-recognized. Increased awareness of potential contamination of herbal products during harvesting is important. Physicians should continue to enhance their knowledge of herbal supplements and be prudent in monitoring for side effects.