A Rare Case Of Xiao Chai Hu Tang Induced Acute Liver Failure...

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ACCEPTED: CLINICAL VIGNETTES/CASE REPORTS—LIVER

Wopperer, Samuel MS1; Baig, Kamal MD2; Jennings, Joseph MD2; Lalos, Alexander MD3

Author Information

1. MedStar Georgetown University Hospital, Grand Island, NY;

2. Georgetown University Hospital, Washington, DC;

3. MedStar Georgetown University Hospital, Washington, DC

American Journal of Gastroenterology 113():p S1243-S1244, October 2018.

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Herbal and dietary substances (HDS) are now a common cause of liver injury worldwide accounting for up to 20% of all drug induced liver injury (DILI). An accurate diagnosis of HDS-induced liver injury is difficult due to our limited knowledge of causative agents, lack of standard diagnostic criteria, and difficulty in establishing exposure timelines. We present a case of a previously healthy female who developed acute liver failure (ALF) after taking Xiao Chai Hu Tang (XCHT). This case highlights the potential of this herbal substance to cause severe liver injury.

A 54-year old female without a history of liver disease presented with 3-weeks of jaundice, abdominal distension, and pedal edema. She denied risk factors for viral hepatitis but admitted to consuming two alcohol units daily. Initial AST, ALT, total bilirubin, and INR were 468 IU/L, 414 IU/L, 11.7 mg/dL, and 4.0, respectively. Imaging revealed a slightly nodular/retracted liver with splenomegaly and ascites. Viral serologies, ANA, and ASMA were negative, and IgG was 1,050 mg/dL. A biopsy revealed extensive bile duct proliferation, fibrosis, and necrosis with no viable hepatocytes. This was not concordant with autoimmune or alcoholic hepatitis, so DILI was suspected. She only noted recent use of a “Chinese herb”, XCHT, and a RUCAM of 7 was assigned. Prednisone was not initiated. Her bilirubin and INR continued to rise, and on the third day of hospitalization, she developed asterixis. She underwent a liver transplant, and the final explant showed “fibrous septae and bile duct proliferation consistent with submassive necrosis with remaining parenchyma showing regenerating nodules and cholestasis.”

XCHT induced ALF has been previously described. Our case is somewhat unique in that this injury led to ALF and liver transplant. Most injuries in the literature have been less severe and have occurred in patients with an underlying HBV infection. In a published review of 24 cases of XCHT induced liver injury, 19 had concurrent HBV hepatitis. Additionally, biopsies from four cases of purely XCHT induced liver injury showed centrilobular confluent or spotty necrosis, microvesicular steatosis, and cholestasis, while our patient had submassive necrosis.

This case serves as a reminder that in a time of increased dietary supplement use, DILI should be considered when conventional causes of ALF have been ruled out and a detailed review of substances ingested especially HDS should be completed.

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A Rare Case of Xiao Chai Hu Tang Induced Acute Liver Failure: 2177 Official journal of the American College of Gastroenterology | ACG113:S1243-S1244, October 2018.

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