Going Green is Not Always Safe

Abstract

Purpose: Drug-induced liver injury is the leading cause of acute liver failure in the United States, but the ability to ascribe hepatic injury confidently to a specific drug remains a challenging and often difficult pursuit. We report the first case of granulomatous hepatitis induced by Sarapin®, a medication derived from the carnivorous plant Sarracenia purpurea (Pitcher Plant). Sarapin® is used as injections for regional analgesia in neuropathic pain. An 85 year old woman with history of osteopenia, hypertension, hyperlipidemia, coronary artery disease and cerebral vascular accident was admitted for chest pain and hypertension. She denied using alcohol. The laboratory tests done initially showed abnormal liver function tests (ALT 724 IU/L, AST 562 IU/L, and Alkaline Phosphatase 184 IU/L), new findings from normal values 4 months prior to admission. Albumin, total protein, bilirubin and coagulation tests were normal. Home medication review showed a new substance recently added to her multiregimen medication, called Sarapin®, in the form of locally administered injections for chronic joints pain. These injections have been administered in various locations in 6 consecutive sessions over the last 3 months. In the next 6 days the patient described mild intermittent right upper abdominal pain and transaminases continued to climb slowly to ALT 993 UI/L, AST 779 UI/L, Alkaline Phosphatase 260 UI/L. Core needle biopsy of the liver showed preserved hepatic architecture with mixed chronic inflammatory infiltrate disease. Several non-caseating granulomas were seen. No steatosis was present. Trichrome stains showed portal and periportal fibrosis. Polarizing microscopy did not reveal foreign material. Special stains for acid-fast bacilli and fungi were negative. The diagnostic workup helped in ruling out sarcoidosis, mycobacterial and fungal infection or primary biliary cirrhosis as possible cause for her granulomatous hepatitis. After discontinuing Sarapin® injections the transaminases and alkaline phosphatase decreased slowly, the patient became asymptomatic and was discharged. The follow up done one week later revealed normalizing liver function tests. This case illustrates the potential for liver toxicity with the use of Sarapin® and the difficulty for its identification as a single offending agent. The lack of any information in the literature regarding liver toxicity after the use of Sarapin® makes the confirmation of our diagnosis even harder. Our patient is the first case reported as Sarapin® induced hepatitis. Monitoring the transaminases on a patient getting Sarapin® is prudent. Further observations and studies are necessary to clarify the relation between the human liver and the Pitcher Plant.