Drug Induced Liver Injury Caused by Herbal Male Enhancing products: A Rare Case

Abstract

Introduction: Diagnosis of drug induced liver Injury remains a significant challenge as it is an important cause of morbidity and mortality. We are presenting a rare case of DILI caused by male enhancing herbal products. Case Report: 25 year old male presented with right upper quardant discomfort and yellow discoloration of skin of 1 month duration. Patient denied IV drug use, Alcohol use or unprotected sexual activity. Patient reported taking herbal male enhancing supplements regularly which includes fimbriata, pregnanas and megastigmane under the trade name “Yellow Demon” and Etiocholenolol and LGD-Elite under the name “Alpha Male”. On Physical Exam patient had jaundice, RUQ tenderness and hepatomegaly. Laboratory data showed severe direct hyperbilirubinemia with T.Bili of 38, D.Bili of 23 and mild elevation of ALP with preserved synthetic liver function. Infectious hepatitis work up was negative. US hepatobiliary showed normal liver parenchyma and normal biliary tract. Liver biopsy showed pathologic findings consistent with moderate to severe cholestasis secondary to acute hepatocellular injury consistent with drug induced acute lobular hepatitis. Patient was started on Ursodiol and Cholestyramine. He was advised to stop above mentioned products. Patient's symptoms improved and bilirubin normalized within 3 months. Discussion: Over 1000 medications and herbal products have been implicated in the development of drug induced liver injury. This case presents what is to our knowledge the first case report in the literature caused by these male enhancing herbal medicines. The strong and consistent association of DILI susceptibility with various single nucleotide polymorphisms in the HLA region suggests that the host immune response plays a key role in pathogenesis. Immediate cessation of the drug is key to prevent or minimize progressive damage. Treatment is largely supportive. The exact incidence of DILI is difficult to determine and is probably underreported. Therefore, from a pharmacological perspective, a careful separation of products into their multiple components together with pharmacological and toxicological studies is needed to determine the most important taxa and their adverse effects. From a clinical point of view, education of patients and physicians is essential, particularly regarding clarification and emphasis that “not all natural products are safe”. These elements can change the perspective of the problem.Figure 1