Herbal medications are being increasingly used by the American population especially for common conditions like arthritis. They have been reported to cause adverse effects, including significant hepatotoxicity, but reporting remains sporadic. We report here a patient who developed drug induced liver injury following the intake of Move Free, which is an over-the-counter arthritis supplement. We propose that Chinese skullcap, which is one of the herbal ingredients of the medication, is responsible for the adverse event. There was a strong temporal association between the intake of supplement and onset of symptoms, and also there have been a few recent case reports implicating the same component. A unique observation in our case is the occurrence of pulmonary infiltrates simultaneously with the hepatotoxicity, and this side effect has not been well documented before. Both the hepatic and pulmonary complications completely resolved over few weeks after the patient stopped taking the medication. Since these supplements are readily available over the counter, we feel that it is important to document possible adverse outcomes to raise awareness in the medical community and also among patients. 1. Introduction More than a third of Americans use herbal medications for various purported beneficial effects and most of them do not disclose their use to physicians [1, 2]. These medications are considered by patients to be safe as they are of natural origin. Unfortunately they can cause serious adverse effects. The process of FDA regulation of these supplements is less rigorous than that for drugs, so their adverse effects are not well documented. Nonetheless it is important to document cases of serious adverse outcomes related to herbal supplements, both to raise awareness and hopefully to prevent recurrence. We report here a case of hepatotoxicity related to use of an over-the-counter arthritis supplement. 2. Case Report A 62-year-old Caucasian female with a history of diabetes mellitus was hospitalized for acute onset of shortness of breath. She was found to be hypoxic, and chest X-ray showed bilateral interstitial infiltrates. She was incidentally found to have abnormal liver tests in the form of elevated aminotransferases and hyperbilirubinemia (Figure 1). The patient did not give a history of prior liver disease, did not drink alcohol, and had no risk factors for acute viral hepatitis. Her most recent previous liver tests (from 3 years ago) had been completely normal. Physical examination revealed jaundice but no splenomegaly, asterixis, or other stigmata of
References
[1]
P. M. Barnes, B. Bloom, and R. L. Nahin, “Complementary and alternative medicine use among adults and children: United States, 2007,” National Health Statistics Reports, vol. 10, no. 12, pp. 1–23, 2009.
[2]
D. M. Eisenberg, R. C. Kessler, M. I. Van Rompay et al., “Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey,” Annals of Internal Medicine, vol. 135, no. 5, pp. 344–351, 2001.
[3]
A. Nadir, S. Agrawal, P. D. King, and J. B. Marshall, “Acute hepatitis associated with the use of a Chinese herbal product, ma-huang,” American Journal of Gastroenterology, vol. 91, no. 7, pp. 1436–1438, 1996.
[4]
W. Sanchez, J. T. Maple, L. J. Burgart, and P. S. Kamath, “Severe hepatotoxicity associated with use of a dietary supplement containing usnic acid,” Mayo Clinic Proceedings, vol. 81, no. 4, pp. 541–544, 2006.
[5]
D. Larrey and G. P. Pageaux, “Hepatotoxicity of herbal remedies and mushrooms,” Seminars in Liver Disease, vol. 15, no. 3, pp. 183–188, 1995.
[6]
J. D. Estes, D. Stolpman, A. Olyaei et al., “High prevalence of potentially hepatotoxic herbal supplement use in patients with fulminant hepatic failure,” Archives of Surgery, vol. 138, no. 8, pp. 852–858, 2003.
[7]
J. J. Liu, T. S. Huang, W. F. Cheng, and F. J. Lu, “Baicalein and baicalin are potent inhibitors of angiogenesis: inhibition of endothelial cell proliferation, migration and differentiation,” International Journal of Cancer, vol. 106, no. 4, pp. 559–565, 2003.
[8]
Y. C. Shen, W. F. Chiou, Y. C. Chou, and C. F. Chen, “Mechanisms in mediating the anti-inflammatory effects of baicalin and baicalein in human leukocytes,” European Journal of Pharmacology, vol. 465, no. 1-2, pp. 171–181, 2003.
[9]
B. P. Burnett, S. Silva, M. H. Mesches, S. Wilson, and Q. Jia, “Safety evaluation of a combination, defined extract of Scutellaria baicalensis and Acacia catechu,” Journal of Food Biochemistry, vol. 31, no. 6, pp. 797–825, 2007.
[10]
C. A. Naranjo, U. Busto, and E. M. Sellers, “A method for estimating the probability of adverse drug reactions,” Clinical Pharmacology and Therapeutics, vol. 30, no. 2, pp. 239–245, 1981.
[11]
J. Harvey and D. G. Colin-Jones, “Mistletoe hepatitis,” British Medical Journal, vol. 282, no. 6259, pp. 186–187, 1981.
[12]
F. B. MacGregor, V. E. Abernethy, S. Dahabra, I. Cobden, and P. C. Hayes, “Hepatotoxicity of herbal remedies,” British Medical Journal, vol. 299, no. 6708, pp. 1156–1157, 1989.
[13]
S. H. Caldwell, J. W. Feeley, T. F. Wieboldt, P. L. Featherston, and R. C. Dickson, “Acute hepatitis with use of over-the-counter herbal remedies,” Virginia Medical Quarterly, vol. 121, no. 1, pp. 31–33, 1994.
[14]
S. A. Linnebur, O. C. Rapacchietta, and M. Vejar, “Hepatotoxicity associated with Chinese skullcap contained in move free advanced dietary supplement: two case reports and review of the literature,” Pharmacotherapy, vol. 30, no. 7, 2010.
[15]
L. Yang, A. Aronsohn, J. Hart, et al., “Herbal hepatoxicity from Chinese skullcap: a case report,” World Journal of Hepatology, vol. 4, no. 7, pp. 231–233, 2012.
[16]
F. G. Miskelly and L. I. Goodyer, “Hepatic and pulmonary complications of herbal medicines,” Postgraduate Medical Journal, vol. 68, no. 805, p. 935, 1992.
