S3204 Turmeric-Induced Liver Injury: A Rare Case of DILI

Abstract

Introduction: Turmeric, a plant prevalent in South Asia, is often marketed to be safe, with many benefits including antioxidant and anti-inflammatory effects. Hepatotoxicity, a rare adverse effect, has only been documented in a few case reports. Here we present a case of turmeric Drug Induced Liver Injury (DILI) with normalization of liver function tests after its cessation. Case Description/Methods: A 62-year-old female with a history of hypertension presented with nausea and generalized abdominal pain for five days. She denied taking medications other than hydrochlorothiazide. Further interview noted that she initiated turmeric tea over the preceding three weeks. On physical exam, she had scleral icterus and right upper quadrant tenderness. Laboratory workup showed AST 1510 U/L, ALT 1889 U/L, total bilirubin 13.9 mg/dL, direct bilirubin 8.1 mg/dL, ALP 134 U/L, LDH 542 U/L, with an ALT/LDH ratio of 3.49. INR was normal. Ultrasound revealed findings consistent with acute hepatitis. Ferritin, ceruloplasmin, and acetaminophen levels were normal. Alpha-1-antitrypsin, anti-mitochondrial, and anti-smooth muscle antibodies were unremarkable. Viral serologies were normal. The patient improved with turmeric cessation, with complete resolution of abnormal liver enzymes on follow-up. Discussion: Turmeric, previously considered safe, has now been reported to be associated with DILI in a few case reports. Our case adds to the growing body of evidence supporting turmeric induced DILI. Although we could not uncover the exact dose, we do establish a high probability of adverse effects from turmeric using the validated Roussel Uclaf Causality Method (RUCAM) scoring system. Our patient scored 9, with a score >8 representing a high probability. Turmeric induced DILI is thought to be both dose dependent and associated with formulations that contain supplements or nanoparticles that increase turmeric’s bioavailability. Lombardi et al. and Sohal et al. for example both report several cases of acute hepatitis associated with turmeric preparations developed with piperine (black pepper), which has been shown to increase the absorption of turmeric by 2000%. In our case, the patient’s turmeric tea also included black pepper, which likely explains the hepatotoxicity. This case underscores the importance of supplement history, with an emphasis on turmeric, when evaluating for potential causes of DILI.