1
|
Herb-Induced Liver Injury by Cimicifuga racemosa and Thuja occidentalis Herbal Medications for Fertility. Case Rep Gastrointest Med 2021; 2021:8858310. [PMID: 33532101 PMCID: PMC7814407 DOI: 10.1155/2021/8858310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 11/30/2022] Open
Abstract
Herb-induced liver injury (HILI) is often an underreported sequela for many herbal remedies due to the lack of safety measurements involving these supplements. Cimicifuga racemosa and Thuja occidentalis are two herbal medications commonly used by women for fertility purposes. Many herbal preparations of these two supplements do not specify the risks behind their individual usage. We present a case of a 40-year-old woman who developed acute liver injury after concomitant use of these two products assessed for causality using the updated RUCAM. Upon a detailed investigation, the patient did not have evidence of underlying liver disease or any other risk factors to explain her presentation. After discontinuation of both herbal supplements, the patient had complete resolution of her symptoms and a significant improvement of transaminitis. This report highlights the importance of potential risk of hepatotoxicity induced by concomitant use of Cimicifuga racemosa and Thuja occidentalis.
Collapse
|
2
|
Antigen presentation, autoantibody production, and therapeutic targets in autoimmune liver disease. Cell Mol Immunol 2020; 18:92-111. [PMID: 33110250 PMCID: PMC7852534 DOI: 10.1038/s41423-020-00568-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 09/24/2020] [Indexed: 02/07/2023] Open
Abstract
The liver is an important immunological organ that controls systemic tolerance. The liver harbors professional and unconventional antigen-presenting cells that are crucial for tolerance induction and maintenance. Orchestrating the immune response in homeostasis depends on a healthy and well-toned immunological liver microenvironment, which is maintained by the crosstalk of liver-resident antigen-presenting cells and intrahepatic and liver-infiltrating leukocytes. In response to pathogens or autoantigens, tolerance is disrupted by unknown mechanisms. Intrahepatic parenchymal and nonparenchymal cells exhibit unique antigen-presenting properties. The presentation of microbial and endogenous lipid-, metabolite- and peptide-derived antigens from the gut via conventional and nonconventional mechanisms can educate intrahepatic immune cells and elicit effector responses or tolerance. Perturbation of this balance results in autoimmune liver diseases, such as autoimmune hepatitis, primary biliary cholangitis, and primary sclerosing cholangitis. Although the exact etiologies of these autoimmune liver diseases are unknown, it is thought that the disruption of tolerance towards self-antigens and microbial metabolites and lipids, as well as alterations in bile acid composition, may result in changes in effector cell activation and polarization and may reduce or impair protective anti-inflammatory regulatory T and B cell responses. Additionally, the canonical and noncanonical transmission of antigens and antigen:MHC complexes via trogocytosis or extracellular vesicles between different (non) immune cells in the liver may play a role in the induction of hepatic inflammation and tolerance. Here, we summarize emerging aspects of antigen presentation, autoantibody production, and the application of novel therapeutic approaches in the characterization and treatment of autoimmune liver diseases.
Collapse
|
3
|
Lu JG, Ji P, French SW. The Major Histocompatibility Complex Class II-CD4 Immunologic Synapse in Alcoholic Hepatitis and Autoimmune Liver Pathology: The Role of Aberrant Major Histocompatibility Complex Class II in Hepatocytes. THE AMERICAN JOURNAL OF PATHOLOGY 2019; 190:25-32. [PMID: 31669415 DOI: 10.1016/j.ajpath.2019.09.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 08/27/2019] [Accepted: 09/24/2019] [Indexed: 12/12/2022]
Abstract
The major histocompatibility complex class II (MHC II)-CD4 immunologic synapse is classically described between the T-cell receptor of CD4-positive lymphocytes and MHC II on antigen-presenting cells. This interaction and others between surrounding costimulatory and checkpoint molecules promote differentiation of naïve CD4 T lymphocytes into helper T cells subtypes, including types 1, 2, and 17 helper T cells, that have more tailored immunologic responses. Although MHC II is mainly produced by professional antigen-presenting cells, it can be aberrantly produced by other cell types, including hepatocytes in various liver pathologies, such as autoimmune hepatitis and alcoholic hepatitis. This can lead to direct targeting of hepatocytes by CD4-positive lymphocytes, which form an immunologic synapse with the hepatocyte. The lymphocytes internalize the MHC II-CD4 complexes in a phagocytosis-like mechanism and in the process eat the hepatocyte piece by piece. We review the evidence for this mechanism and the role of these autoimmune responses in various liver diseases, including alcoholic hepatitis, autoimmune hepatitis, and primary biliary cirrhosis. The role of aberrant MHC II in malignancy, including hepatocellular carcinoma, is also reviewed. Further understanding of this mechanism can lead to better understanding of the immune mechanisms involved in these liver pathologies, with potential diagnostic and therapeutic applications.
Collapse
Affiliation(s)
- Jiajie G Lu
- Department of Pathology, Harbor-UCLA Medical Center, Torrance, California.
| | - Ping Ji
- Department of Pathology, Harbor-UCLA Medical Center, Torrance, California
| | - Samuel W French
- Department of Pathology, Harbor-UCLA Medical Center, Torrance, California
| |
Collapse
|
4
|
French SW, Lu JG. Piecemeal necrosis is due to the immunologic synapse formation and internalization of intact TCR-MHC II complexes by CD4 T cells. Exp Mol Pathol 2018; 105:150-152. [PMID: 30009774 DOI: 10.1016/j.yexmp.2018.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/11/2018] [Indexed: 11/27/2022]
Abstract
The nature of the immunologic synapse in autoimmune hepatitis is defined. This process involves the T cell receptor (TCR) which binds to the hepatocyte antigen presenting major histocompatibility complex (MHC) on the plasma membrane. This complex is quickly removed from the liver cell and taken into the T cell cytoplasm to be digested by the lysosome. The liver cell is gradually diminished to the point of its total removal by the lymphocytes binding to it.
Collapse
Affiliation(s)
- Samuel W French
- Harbor-UCLA Medical Center, 1000 W. Carson St., Torrance, CA 90500, United States.
| | - Jiajie G Lu
- Harbor-UCLA Medical Center, 1000 W. Carson St., Torrance, CA 90500, United States
| |
Collapse
|
5
|
Butler DC, Lewin DN, Batalis NI. Differential Diagnosis of Hepatic Necrosis Encountered at Autopsy. Acad Forensic Pathol 2018; 8:256-295. [PMID: 31240042 DOI: 10.1177/1925362118782056] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 04/13/2018] [Indexed: 12/13/2022]
Abstract
The liver is subject to a variety of extrinsic and intrinsic insults that manifest with both specific and nonspecific patterns of necrosis. In the autopsy setting, these patterns are often encountered as incidental findings or even causes of death. There are several etiologies of hepatic necrosis, including toxins, drug injuries, viral infections, ischemic injuries, and metabolic disease, all of which possess overlapping gross and histologic presentations. Nonetheless, patterned necrosis in the context of clinical and demographic history allows for the forensic pathologist to develop a differential diagnosis, which may then be pruned into a specific or likely cause. The aim of the following review is to elucidate these patterns in the context of the liver diseases from which they arise with the goal developing a differential diagnosis and ultimate determination of etiology. Acad Forensic Pathol. 2018 8(2): 256-295.
Collapse
|
6
|
Berce C, Lucan C, Petrushev B, Boca S, Miclean M, Sarpataki O, Astilean S, Buzoianu A, Tomuleasa C, Bojan A. In vivo assessment of bone marrow toxicity by gold nanoparticle-based bioconjugates in Crl:CD1(ICR) mice. Int J Nanomedicine 2016; 11:4261-73. [PMID: 27621620 PMCID: PMC5012637 DOI: 10.2147/ijn.s108711] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Introduction The present study aimed at evaluating the biodistribution of Tween® 20-gold nanoparticle (GNP) conjugates and their potential toxicity on the bone marrow before moving on to Phase I clinical trials. Materials and methods Tween® 20-conjugated GNPs were injected intravenously for 21 days in male Crl:CD1(ICR) mice. Body weight of the mice was evaluated each day. After the sub-chronic Tween® 20-GNPs administration, blood samples were harvested, and a full blood count was done individually. Total Au quantity from all major organs was assessed using inductively coupled plasma mass spectrometry. One femur and the sternum obtained from each animal were used for histological assessment. Results Our data showed that the Tween® 20-GNP conjugates were found in large quantities in the bladder. Au was shown to accumulate in the hematopoietic bone tissue, with significant side effects such as leucopoiesis and megakaryopoiesis. The mice had a higher white blood cell and platelet count as opposed to the control group. This suggested that the previously described leukopenic effects of isoflurane were overridden by the leucopoietic effects of Tween® 20-GNPs. Conclusion It was uncertain whether the mice were reactive to Au as it is a foreign substance to the tissues or whether the side effects observed were a precursor condition of a more severe hematological condition. Au was found to be hepatotoxic, urging the need for further studies in order to achieve better in vivo compliance and exploit the immense potential of GNPs in cancer pharmacology.
Collapse
Affiliation(s)
| | | | - Bobe Petrushev
- Research Center for Functional Genomics and Translational Medicine; Department of Pathology, Iuliu Hatieganu University of Medicine and Pharmacy
| | - Sanda Boca
- Nanobiophotonics and Laser Microscopy Center, Interdisciplinary Research in Bio-Nano-Sciences - Faculty of Physics, Babes-Bolyai University
| | | | | | - Simion Astilean
- Nanobiophotonics and Laser Microscopy Center, Interdisciplinary Research in Bio-Nano-Sciences - Faculty of Physics, Babes-Bolyai University
| | - Anca Buzoianu
- Department of Pharmacology, Iuliu Hatieganu University of Medicine and Pharmacy
| | - Ciprian Tomuleasa
- Research Center for Functional Genomics and Translational Medicine; Department of Hematology, Ion Chiricuta Oncology Institute
| | - Anca Bojan
- Department of Hematology, Ion Chiricuta Oncology Institute; Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| |
Collapse
|
7
|
Wei CH, Penunuri A, Karpouzas G, Fleishman W, Datta A, French SW. Troxis necrosis, a novel mechanism for drug-induced hepatitis secondary to immunomodulatory therapy. Exp Mol Pathol 2015; 99:341-3. [PMID: 26297838 DOI: 10.1016/j.yexmp.2015.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 08/13/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVES A case of drug-induced hepatitis mediated by troxis necrosis, a form of autoimmune hepatitis, is described. METHODS Clinical data, light and electron microscopy of an ultrasound-guided core needle liver biopsy specimen, were examined to investigate the cause of transaminitis in a 26year old male patient on Cellcept and Plaquenil for the treatment of lupus erythematosus. A systematic PUBMED review of troxis necrosis as the underlying mechanism for drug-induced hepatitis was performed. RESULTS Liver function tests (LFTs) were significant for elevated AST (305) and ALT (174); the autoimmune workup was significant for anti-ANA positivity and α-SMA negativity. On light microscopy, the liver biopsy shows focal areas of lymphocytic infiltrates surrounding and forming immunologic synapses with lobular hepatocytes, indicating lobular hepatitis of autoimmune nature. Electron microscopy confirmed the presence of immunologic synapses. Upon cessation of the offending medications, the LFTs returned to baseline with no further intervention. Literature search yielded 7 previously reported cases of drug-induced hepatitis mediated by troxis necrosis. CONCLUSION Troxis necrosis is a novel mechanism for drug-induced hepatitis, including immunomodulatory medications including a monoclonal anti-TWEAK antibody and Cellcept and Plaquenil, two widely used immunosuppression/anti-rejection medications.
Collapse
Affiliation(s)
- Christina H Wei
- Department of Pathology and Medicine, Harbor-UCLA Medical Center, Torrance, CA 90509, United States
| | - Andrew Penunuri
- Department of Pathology and Medicine, Harbor-UCLA Medical Center, Torrance, CA 90509, United States
| | - George Karpouzas
- Department of Medicine, Division of Rheumatology, Harbor-UCLA Medical Center, Torrance, CA 90509, United States
| | - Wayne Fleishman
- Department of Pathology and Medicine, Harbor-UCLA Medical Center, Torrance, CA 90509, United States
| | - Anuj Datta
- Department of Medicine, Division of Rheumatology, Harbor-UCLA Medical Center, Torrance, CA 90509, United States
| | - Samuel W French
- Department of Pathology and Medicine, Harbor-UCLA Medical Center, Torrance, CA 90509, United States
| |
Collapse
|
8
|
French SW, Enbom ET. Piecemeal necrosis of the liver revisited a review. Exp Mol Pathol 2014; 96:307-9. [PMID: 24704429 DOI: 10.1016/j.yexmp.2014.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 03/25/2014] [Indexed: 11/16/2022]
Abstract
Piecemeal necrosis of the liver is thought to lead to liver cell necrosis. However the process does not lead to necrosis but rather lead to gradual progressive piecemeal removal of liver cell cytoplasm by T lymphocytes which are sensitized to antigens presented on the liver cell surface to form the immunologic synapse. The cytoplasm is taken up by the T cell and digested by the lysosome in the lymphocyte. By this mechanism the liver cell gradually disappears like the Cheshire cat in Alice in Wonderland.
Collapse
Affiliation(s)
- S W French
- Department of Pathology, Habor-UCLA Medical Center, Torrance, CA 90509, United States.
| | - E T Enbom
- Department of Pathology, Habor-UCLA Medical Center, Torrance, CA 90509, United States
| |
Collapse
|
9
|
Enbom ET, Le MD, Oesterich L, Rutgers J, French SW. Mechanism of hepatotoxicity due to black cohosh (Cimicifuga racemosa): histological, immunohistochemical and electron microscopy analysis of two liver biopsies with clinical correlation. Exp Mol Pathol 2014; 96:279-83. [PMID: 24657312 DOI: 10.1016/j.yexmp.2014.03.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 03/12/2014] [Indexed: 01/15/2023]
Abstract
BACKGROUND Consumption of herbal supplements in the developed world remains high. Cimicifuga racemosa (C. racemosa) extract, or black cohosh, is widely used as a hormone replacing and an anti-inflammatory agent, and has been shown to cause idiosyncratic hepatitis. The mechanism of acute liver injury in those cases is unclear. To date, hepatotoxic effects of C. racemosa have been studied mostly in vitro and in animal models. Data on human tissue is extremely limited, and mostly confined to histological findings of explanted livers. METHODS We evaluated clinical data and examined surgical diagnostic liver biopsy specimens obtained from two female patients, who developed acute submassive liver necrosis, following consumption of C. racemosa. Both patients presented with acute elevation of liver enzymes, cholestasis, absence of reactivity to hepatitis A, B and C antibodies, and weak non-specific positivity for autoimmune serological markers. Initial histological interpretation of the biopsies, with focus on hepatic parenchyma and portal tracts, was done by light microscopy, followed by special stain series and immunohistochemical studies, including Cam 5.2, AE1/AE3, reticulin, α-actin, sirius red, and PAS with diastase. Areas of prominent lymphocytic infiltration of the periportal liver plate, observed microscopically, were further evaluated by electron microscopy (EM). 4HNE adduction study, an immunofluorescent assay, was performed to detect products of the oxidative damage and their localization in the liver parenchyma. RESULTS Oxidative damage was evident by accumulation of 4HNE protein adducts in the cytoplasm of hepatocytes, secondary lysosomes and macrophages. We hypothesize that the adducted proteins, accumulated in the liver parenchyma, serve as autoantigens, which provoke an autoimmune response, and cause migration of lymphocytes to the affected regions. The formation of immunological synapses between hepatocytes and lymphocytes, predominantly T-lymphocytes, is demonstrated by electron microscopy. The autoimmune response induces piecemeal, or troxis necrosis of hepatocytes, a well described biological phenomenon, where lymphocytes gradually remove hepatocytes in a piecemeal fashion, slowly consuming them and leaving fragments of liver cells, or nubbins of anuclear cytoplasm of liver cell, at the interface between lymphocytes and hepatocytes. CONCLUSION The pattern of pathological injury of liver cells in both patients, following consumption of black cohosh, is identical to troxis necrosis, seen during autoimmune hepatitis. Recognition of the possibility of the acute hepatic injury by the herbal supplement black cohosh is essential for early accurate diagnosis, and timely patient management.
Collapse
Affiliation(s)
- Elena T Enbom
- Department of Pathology and Laboratory Medicine, Harbor-UCLA Medical Center, Torrance, CA, United States.
| | - Mary D Le
- Department of Pathology and Laboratory Medicine, Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Leslie Oesterich
- Department of Internal Medicine, Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Joanne Rutgers
- Department of Pathology Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles CA, United States
| | - Samuel W French
- Department of Pathology and Laboratory Medicine, Harbor-UCLA Medical Center, Torrance, CA, United States
| |
Collapse
|
10
|
Alcohol induced hepatic degeneration in a hepatitis C virus core protein transgenic mouse model. Int J Mol Sci 2014; 15:4126-41. [PMID: 24608925 PMCID: PMC3975388 DOI: 10.3390/ijms15034126] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 02/08/2014] [Accepted: 02/26/2014] [Indexed: 02/07/2023] Open
Abstract
Hepatitis C virus (HCV) has become a major public health issue. It is prevalent in most countries. HCV infection frequently begins without clinical symptoms, before progressing to persistent viremia, chronic hepatitis, cirrhosis and hepatocellular carcinoma (HCC) in the majority of patients (70% to 80%). Alcohol is an independent cofactor that accelerates the development of HCC in chronic hepatitis C patients. The purpose of the current study was to evaluate ethanol-induced hepatic changes in HCV core-Tg mice and mutant core Tg mice. Wild type (NTG), core wild-Tg mice (TG-K), mutant core 116-Tg mice (TG-116) and mutant core 99-Tg mice (TG-99) were used in this investigation. All groups were given drinking water with 10% ethanol and 5% sucrose for 13 weeks. To observe liver morphological changes, we performed histopathological and immunohistochemical examinations. Histopathologically, NTG, TG-K and TG-116 mice showed moderate centrilobular necrosis, while severe centrilobular necrosis and hepatocyte dissociation were observed in TG-99 mice with increasing lymphocyte infiltration and piecemeal necrosis. In all groups, a small amount of collagen fiber was found, principally in portal areas. None of the mice were found to have myofibroblasts based on immunohistochemical staining specific for α-SMA. CYP2E1-positive cells were clearly detected in the centrilobular area in all groups. In the TG-99 mice, we also observed cells positive for CK8/18, TGF-β1 and phosphorylated (p)-Smad2/3 and p21 around the necrotic hepatocytes in the centrilobular area (p < 0.01). Based on our data, alcohol intake induced piecemeal necrosis and hepatocyte dissociation in the TG-99 mice. These phenomena involved activation of the TGF-β1/p-Smad2/3/p21 signaling pathway in hepatocytes. Data from this study will be useful for elucidating the association between alcohol intake and HCV infection.
Collapse
|
11
|
Abstract
The role that inflammatory cell injury plays in the pathogenesis of alcoholic liver disease is reviewed with emphasis on granulocytes and immunocytes. New insights regarding the mechanism of lymphocytic migration from the portal vein and lymphocytic-mediated hepatocellular injury are also reviewed.
Collapse
Affiliation(s)
- Samuel W French
- Department of Pathology, Harbor-UCLA Medical Center, Torrance, CA 90509, USA.
| |
Collapse
|