Goldenseal Root Powder (Hydrastis Canadensis) Associated Hepatotoxicity

Abstract

Introduction: The use of herbal supplements has increased in the United States in last decade. It may be associated with significant side effects. We report a patient with hepatotoxicity following ingestion of herbal preparation, Goldenseal root powder. Case report: A 60-year-old female was admitted to the hospital with delusional behavior. A family member had recently noticed that she was jaundiced. The patient had no prior history of liver disease. Her past medical history was significant for paranoid schizophrenia and diabetes mellitus. She denied taking any medication apart from goldenseal root powder for four months prior to admission, for general wellbeing. She did not smoke or drink alcohol. There was no history of drug abuse. Her physical examination was unremarkable apart from icteric sclera. Her liver function test showed total bilirubin of 18.8 mg/dL, direct bilirubin 11.8 mg/dL, aspartate transaminase (AST) 94 U/L, alanine transaminase (ALT) 76 U/L, alkaline phosphatase 1832 U/L, albumin 2.4 g/dL, and INR 1.0. An abdominal computed tomography (CT) and liver ultrasound showed hepatomegaly without signs of cholecystitis or extra hepatic obstruction. Viral hepatitis serology, antinuclear antibody, anti-mitochondrial antibody, anti-smooth muscle antibody, liver/kidney microsome antibodies, ceruloplasmin level, and iron panel were normal. A liver biopsy showed cholestasis with canalicular and intraductular bile plugs, compatible with drug-induced cholestatic hepatitis. The patient's jaundice improved while in the hospital. Patient was instructed to stop using goldenseal root powder. Outpatient follow-up showed continued improvement in her liver function test. Discussion: Herbal medicines are widely perceived by the public as an innocuous health aid. Goldenseal root powder is thought to be hepatoprotective in animal models by inhibiting CYP2E1 enzyme.1 However, some herbal medicines may be associated with hepatotoxicity. Our patient's liver function improved after discontinuation of goldenseal root powder and no other etiology of cholestatic hepatitis was identified. This appears to be the first case report in english literature on goldenseal root powder associated hepatotoxicity. Our case highlights that hepatotoxicity should be considered in anyone taking goldenseal root powder.