Expecting the Unexpected: Black Cohosh-induced Hepatotoxicity Leading to Early Cirrhosis

Abstract

Purpose: Herbal supplements are commonly used by patients for various problems. It is a well-known fact that most patients do not tell their physicians regarding use of herbal supplements unless specifically asked. As a result, sometimes important points from drug side effects are missed in history taking. In this context, we present a rare case of Black Cohosh-induced hepatotoxicity leading to early cirrhosis. Case Description: A 44-year-old female with no PMH presented with complaints of painless jaundice for one month. She went to her PCP, where initial work-up revealed that she had elevated LFTs. She was noted to have normal LFTs on her prior lab works. Work-up for viral and autoimmune hepatitis was negative. She was given a trial of steroids on outpatient basis without much improvement. She was referred to inpatient evaluation because of gradual progression of her symptoms. She denied history of alcohol intake, IV drug use, unprotected sex, recent travel outside the U.S., NSAID ingestion or blood transfusions. She reported no abdominal pain, fever, chills, nausea vomiting or diarrhea. She did report generalized itching, arthralgia and fatigue. She interestingly reported that she started taking Black Cohosh for alleviation of her menstrual symptoms about one month back. Her exam was remarkable for marked scleral icterus and jaundiced skin. On admission, her LFT showed TBil =20, AST=420, ALT=215, AlkPhos=201, Platelets= 135, INR 1.2 and Albumin=2.4. Ultrasound abdomen showed nodular contour of liver consistent with cirrhosis. Further work-up ruled out Wilson's disease, Hemochromatosis, AMA negative PBC and autoimmune hepatitis. Liver biopsy was performed, which showed histologic pattern consistent with cholestasis, hepatocellular injury and early cirrhosis. Given patient's history of Black Cohosh use and the timing of her abnormal liver chemistries, it was clinically evident the culprit agent was Black Cohosh. Her symptoms improved, and her LFT's normalized after she stopped taking Black Cohosh. Discussion: Black Cohosh, also named as Cimicifuga racemosa, is among commonly used herbal supplements in the United States for menstrual symptoms. There are few case reports available in literature that attribute Black Cohosh to liver injury. In most instances, the liver injury ranges from jaundice, mild transaminasemia to rare cases of fulminant hepatic failure. Our case is unique, since it represents development of accelerated cirrhosis in our patient for a relatively short period of time. This case is to bring awareness amongst clinicians about this potentially unexpected outcome in the backdrop of much-expected drug induced hepatitis.