S2891 Mistletoe Extract-Induced Liver Injury

Abstract

Introduction: Herein we present an unusual case of a patient who presented with liver injury induced by herbal extract containing mistletoe. Case Description/Methods: A 33 year old woman with history of Crohn’s disease and adenocarcinoma of colon with metastasis to right ovary, fallopian tube, and bladder presented with two week history of right upper quadrant abdominal pain, jaundice, and scleral icterus. Labs were significant for total bilirubin 9.9 mg/dL, direct bilirubin 7.3 mg/dL, ALT 183 U/L, AST 136 U/L, and alkaline phosphatase 315 U/L. CT abdomen pelvis with IV contrast demonstrated large amount of retained stool throughout large bowel, sigmoid wall thickening, stable hepatic metastatic disease, and stable splenic lesions. Patient reported using a seven-day course of mistletoe extract in injection form several weeks prior to presentation to assist with boosting her immune system in setting of malignancy. Chronic liver work-up was largely unremarkable. Liver biopsy revealed poorly-differentiated adenocarcinoma but patient was known to have hepatic metastatic disease. There was a plan to repeat biopsy of normal appearing liver if bilirubin and transaminases remained elevated. However, at time of discharge, her total bilirubin improved to 7.6 mg/dL and transaminases normalized to ALT 18 U/L and AST 19 U/L. Patient was scheduled to be seen in clinic and is awaiting follow up. Discussion: Mistletoe extract has been thought to improve quality of life and boost the immune system in cancer patients. However, there has not been enough scientific research to substantiate these claims. In this patient, work up for the underlying etiology of her elevated transaminases and hyperbilirubinemia was largely unremarkable. As such, liver injury induced by herbal extract containing mistletoe was suspected. Patients taking herbal extracts should be advised of the risk of liver injury.