Abstract
Drug Induced Liver Injury (DILI) accounts for at least 10% of adults with liver enzyme elevation [1]. Numerous herbal dietary supplements have been identified as culprits of DILI with almost no reports on Turmeric herbal supplements, a commonly used supplement [2]. We report a case of DILI in a 78 year old Caucasian female presenting with painless jaundice for 1 week. She had no history of analgesic abuse, alcohol use, travel or ill contacts. Her home medications included: aspirin, citalopram, losartan, metformin, oxybutynin, and simvastatin. A month ago, she replaced the simvastatin with a turmeric herbal supplement. She had no other changes in her medications over the last year and has been on simvastatin for 2 years with no adverse effects. Her diagnostic evaluation revealed: (a)an elevation of her AST and ALT >10xULN with a bilirubin of 12.8 mg/dl and an ALP of 171 U/L (b)Normal globulin, IgG and IgG subclass levels (c)Normal MRCP (d)ANA titer of 1:320, ASMA of 1:20, negative anti—LKM and AMA, and (e)an exclusion of viral hepatitis as an etiology of her symptoms. Discontinuation of the supplement resulted in a 40% fall of ALT noted in 7 days from her presentation and a complete normalization of her liver enzyme levels in 42—days. No re—challenge was performed and a liver biopsy wasn't obtained given the rapid improvement in the patient's clinical condition. No liver enzyme elevation was noted on a 4—month follow—up. A RUCAM score was calculated for the supplement which was 8 out of 13 indicating a probable association (with scores >8 indicating a highly probable category; that is the highest association level on the score). This case illustrates the importance of recognizing turmeric herbal supplements as a potential agent causing DILI. It also stresses the importance of a detailed evaluation of all over the counter agents and supplements received by a patient by primary care providers to prevent inadvertent DILI that can lead to significant patient morbidity.
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