S2422 Drug Induced Liver Injury Associated With Oral Aloe Vera Use

Abstract

INTRODUCTION: Herbal preparations and dietary supplements (HDS) use continues to increase over time, due to perceived safety and medicinal benefits. However, there are potential adverse effects associated with HDS such as drug induced liver injury (DILI). We present a case of DILI from the herbal supplement oral Aloe vera ultimately leading to orthotopic liver transplantation (OLT). CASE DESCRIPTION/METHODS: A 64-year-old female patient with a history of obesity, diabetes mellitus type 2, and hyperlipidemia presented to the hospital with jaundice and pruritus. Patient had denied acetaminophen use, alcohol misuse, and had no previous history of chronic liver disease. Patient reported taking daily oral Aloe verasupplement. Notable laboratory values on presentation were aspartate aminotransferase (AST): 1088 U/L, alanine transaminase (ALT): 785 U/L, alkaline phosphatase (ALP): 141 U/L, total bilirubin: 16.6 mg/dL, and international normalized ratio (INR): 3.2. Serological workup for causes of acute hepatitis was negative. She underwent liver biopsy which revealed acute hepatitis without significant fibrosis. Despite discontinuing Aloe vera the patient continued to deteriorate with suspected acute liver failure and ultimately required OLT. The pathological evaluation concluded that the patient had cirrhosis, which was a new finding. Post-transplant course was uneventful. DISCUSSION: DILI is defined as hepatic dysfunction caused by prescription medications, over the counter medications, and HDS after alterative causes have been excluded. Evaluating for DILI can be challenging as its presentation can vary and there are no definitive tests available. Scoring algorithms such as Roussel Uclaf Causality Assessment Model (RUCAM) and Drug-Induced Liver Injury Network (DILIN) expert consensus opinion can help in making the diagnosis of DILI. In our case, the source of hepatotoxicity was likely due to oral Aloe vera. The patient had a RUCAM score of 6 (probable DILI) and DILIN severity grade of 5+ (severe). Liver biopsy also demonstrated acute hepatitis with centrizonal necrosis and cholestasis concerning for DILI. After excluding other etiologies of acute hepatitis the likely source of hepatotoxicity was due to oral Aloe vera. This case highlights the importance of recognizing DILI associated with HDS. The lack of HDS safety regulations and a uniform HDS DILI reporting system, allow for continued HDS DILI outbreaks. Implementing a uniform reporting system can help overcome the obstacles of underreported HDS DILI.Figure 1.: CT abdomen showing an unremarkable liver and spleen.Figure 2.: H&E stain demonstrating acute hepatitis with bridging necrosis associated with canalicular cholestasis and swollen hepatocytes.Figure 3.: Tricome stain showing areas of panacinar necrosis with possible septal fibrosis.