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Acharya SK. Overview of acute liver failure in India. Indian J Gastroenterol 2024; 43:296-311. [PMID: 38722512 DOI: 10.1007/s12664-024-01589-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/08/2024] [Indexed: 05/28/2024]
Abstract
Acute liver failure (ALF) is an infrequent, but serious complication subsequent to severe acute liver injury (sALI) due to various hepatotoxic agents such as hepatotropic virus(es) and drugs such as anti-tubercular medications, paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), antibiotics and anti-cancer and anti-epileptic therapy and due to metabolic and autoimmune disease flares. ALF after sALI presents with encephalopathy associated with prolonged international normalized ratio (INR). Mortality in ALF is high and ranges between 50% and 80%. Due to severe liver damage, multiple sequels consequent to hepatic dysfunction result in complications such as hyperammonemia that culminates in encephalopathy associated with cerebral edema; innate immune paralysis resulting in increased frequency of infections and endotoxemia causing decrease in systemic vascular resistance (SVR) and tissue hypoperfusion and damage-associated molecular patterns (DAMPs) released from damaged hepatic parenchyma inducing pro-inflammatory cytokine storm, which may cause other organ dysfunctions. Certain etiologies such as hepatitis E virus and hepatitis A virus-related ALF or paracetamol-ALF (hyper-acute presentation) have better survival than remaining causes. In addition, if etiology-specific treatment (antivirals for ALF related to hepatitis B virus (HBV) or Herpes simplex virus (HSV) or N-acetylcysteine for paracetamol) is available, then the outcome with treatment is better. About half of the patients can be salvaged with medical therapy. All patients need intensive care and organ support to provide time for the liver to regenerate. Various prognostic models to predict high probability of mortality have been described, which should be used to select patient early during the disease for liver transplantation, which is associated with high long-term survival in these sick patients. The Indian National Association for Study of the Liver (INASL) recommends the ALF-Early Dynamic (ALFED) model as a preferred prognostic model in the Indian scenario, where hepatitis viruses are a dominant etiology of ALF and occur on a naïve liver with good regenerative capacity.
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Affiliation(s)
- Subrat Kumar Acharya
- Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, 751 024, India.
- Fortis Escorts Digestive and Liver Institute, Okhla, New Delhi, 110 025, India.
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Bokan G, Glamočanin T, Mavija Z, Vidović B, Stojanović A, Björnsson ES, Vučić V. Herb-Induced Liver Injury by Ayurvedic Ashwagandha as Assessed for Causality by the Updated RUCAM: An Emerging Cause. Pharmaceuticals (Basel) 2023; 16:1129. [PMID: 37631044 PMCID: PMC10459262 DOI: 10.3390/ph16081129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/26/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Herb-induced liver injury (HILI) caused by herbal supplements, natural products, and products used in traditional medicine are important for differential diagnoses in patients with acute liver injury without an obvious etiology. The root of Withania somnifera (L.) Dunal, commonly known as ashwagandha, has been used in Ayurvedic medicine for thousands of years to promote health and longevity. Due to various biological activities, ashwagandha and its extracts became widespread as herbal supplements on the global market. Although it is generally considered safe, there are several reported cases of ashwagandha-related liver injury, and one case ended with liver transplantation. In this paper, we review all reported cases so far. Additionally, we describe two new cases of ashwagandha hepatotoxicity. In the first case, a 36-year-old man used ashwagandha capsules (450 mg, three times daily) for 6 months before he developed nausea, pruritus, and dark-colored urine. In the second case, a 30-year-old woman developed pruritus after 45 days of using ashwagandha capsules (450 mg). In both cases, serum bilirubin and liver enzymes (aspartate transaminase (AST), alanine transaminase (ALT), and alkaline phosphatase (ALP) were increased. The liver injury pattern was hepatocellular (R-value 11.1) and mixed (R-value 2.6), respectively. The updated Roussel Uclaf Causality Assessment Method (RUCAM) (both cases with a score of seven) indicated a "probable" relationship with ashwagandha. Clinical and liver function improvements were observed after the discontinuation of ashwagandha supplement use. By increasing the data related to ashwagandha-induced liver injury, these reports support that consuming ashwagandha supplements is not without its safety concerns.
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Affiliation(s)
- Goran Bokan
- Internal Medicine Clinic, Department of Gastroenterology and Hepatology, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Republic of Srpska, Bosnia and Herzegovina (Z.M.)
| | - Tanja Glamočanin
- Internal Medicine Clinic, Department of Gastroenterology and Hepatology, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Republic of Srpska, Bosnia and Herzegovina (Z.M.)
- Faculty of Medicine, University of Banja Luka, 78000 Banja Luka, Republic of Srpska, Bosnia and Herzegovina
| | - Zoran Mavija
- Internal Medicine Clinic, Department of Gastroenterology and Hepatology, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Republic of Srpska, Bosnia and Herzegovina (Z.M.)
- Faculty of Medicine, University of Banja Luka, 78000 Banja Luka, Republic of Srpska, Bosnia and Herzegovina
| | - Bojana Vidović
- Faculty of Pharmacy, University of Belgrade, 11000 Belgrade, Serbia
| | - Ana Stojanović
- Bežanijska Kosa Clinical Hospital Center, 11000 Belgrade, Serbia;
| | - Einar S. Björnsson
- Landspitali University Hospital, 101 Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, 101 Reykjavik, Iceland
| | - Vesna Vučić
- Group for Nutritional Biochemistry and Dietology, Centre of Research Excellence in Nutrition and Metabolism, Institute for Medical Research, National Institute of Republic of Serbia, University of Belgrade, 11000 Belgrade, Serbia;
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Nagral A, Rudra OS, Menezes S, Menon S, Shailajan S, Mallakmir S, Reddy R. Herb-induced Liver Injury-A Guide to Approach. Lessons from the Tinospora cordifolia (Giloy) Case Series Story. J Clin Exp Hepatol 2023; 13:360-371. [PMID: 36950495 PMCID: PMC10025683 DOI: 10.1016/j.jceh.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 11/01/2022] [Indexed: 11/08/2022] Open
Abstract
Background Tinospora cordifolia (TC) is being increasingly consumed in India for its health and suggested immune-enhancing benefits in preventing and countering COVID-19. We previously published our experience of hepatotoxicity with self-medication of TC in six individuals. Since herb-induced liver injury (HILI) has been described with Tinospora crispa (TCR) consumption, it was contested that our patients may have mistakenly self-medicated with TCR which is similar in appearance to TC. Methods We collected the four plant samples and two commercial preparations that were consumed by our patients for further analysis. The six samples underwent high performance thin layer chromatography phytochemical analysis and DNA barcoding studies for the confirmation of the genus and species. The four plant part samples which included stems and leaves were also analysed by a botanist for the characteristic morphological and microscopic features. Results Based on morphological, microscopic, phytochemical and DNA studies, the four plant part samples were identified as TC. The two commercial preparations could not be analysed on phytochemical analysis or DNA barcoding studies due to other ingredients that most likely interfered with the analysis. The herb consumed by our study subjects was confirmed to be Tinospora cordifolia. Conclusion We have highlighted the key morphological and phytochemical differences between these two species. We propose an algorithmic approach to accurately identify the implicated herb in cases of HILI. Future studies on causality need to focus on the serological/histopathological identification of active herb/metabolites in human tissues.
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Affiliation(s)
- Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital & Research Centre, Peddar Road, Mumbai, India
- Department of Gastroenterology, Apollo Hospital, Navi Mumbai, India
| | - Omkar S. Rudra
- Department of Critical Care Medicine, Jaslok Hospital & Research Centre, Peddar Road, Mumbai, India
| | - Sherna Menezes
- Department of Gastroenterology, Jaslok Hospital & Research Centre, Peddar Road, Mumbai, India
| | - Sasikumar Menon
- Pharma Analytical Sciences, Ramnarain Ruia Autonomous College, Matunga, Mumbai, India
| | - Sunita Shailajan
- Department of Botany, Ramnarain Ruia Autonomous College, Matunga, Mumbai, India
| | - Snehal Mallakmir
- Centre for Genomic Medicine, Apollo Hospital, Navi Mumbai, India
| | - Rajender Reddy
- Division of Hepatology, University of Pennsylvania, 3400, Spruce Street, 2 Dulles, Philadelphia, PA 19104, USA
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Mahto M, Rai N, Dey S, Kumar R. Anti-F-Actin Antibody Positivity on Indirect Immunofluorescence Assay Following Chinese and Alternative Medicine Therapy: A Case Report. J Lab Physicians 2022. [PMID: 37323599 DOI: 10.1055/s-0042-1758663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
AbstractImmunofluorescence on human epithelial type 2 cells is the standard screening assay for the detection of antinuclear antibodies (ANA). Cytoplasmic speckled patterns are a common finding. However, the less commonly reported ones include the cytoplasmic fibrillar patterns on indirect immunofluorescence technique (IIFT). The cytoplasmic fibrillar patterns include the cytoplasmic linear (AC-15), cytoplasmic filamentous (AC-16), and cytoplasmic segmental (AC-17). We report a case of cytoplasmic linear (F-actin) detected through IIFT during ANA screening in a 77-year-old man and later reconfirmed on liver mosaic biochip through IIFT on vascular smooth muscle substrate (VSM-47) without features suggestive of anti-smooth muscle antibody involvement post-complementary and alternative medicine therapy initiation.
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Affiliation(s)
- Mala Mahto
- Department of Biochemistry, All India Institute of Medical Sciences (AIIMS) Patna, Patna, Bihar, India
| | - Neha Rai
- Department of Biochemistry, All India Institute of Medical Sciences (AIIMS) Patna, Patna, Bihar, India
| | - Soma Dey
- Department of Biochemistry, All India Institute of Medical Sciences (AIIMS) Patna, Patna, Bihar, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences (AIIMS) Patna, Patna, Bihar, India
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Ren Z, Hong Y, Huo Y, Peng L, Lv H, Chen J, Wu Z, Wan C. Prospects of Probiotic Adjuvant Drugs in Clinical Treatment. Nutrients 2022; 14:4723. [PMID: 36432410 PMCID: PMC9697729 DOI: 10.3390/nu14224723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/04/2022] [Accepted: 11/06/2022] [Indexed: 11/11/2022] Open
Abstract
In modern society, where new diseases and viruses are constantly emerging, drugs are still the most important means of resistance. However, adverse effects and diminished efficacy remain the leading cause of treatment failure and a major determinant of impaired health-related quality of life for patients. Clinical studies have shown that the disturbance of the gut microbial structure plays a crucial role in the toxic and side effects of drugs. It is well known that probiotics have the ability to maintain the balance of intestinal microecology, which implies their potential as an adjunct to prevent and alleviate the adverse reactions of drugs and to make medicines play a better role. In addition, in the past decade, probiotics have been found to have excellent prevention and alleviation effects in drug toxicity side effects, such as liver injury. In this review, we summarize the development history of probiotics, discuss the impact on drug side effects of probiotics, and propose the underlying mechanisms. Probiotics will be a new star in the world of complementary medicine.
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Affiliation(s)
- Zhongyue Ren
- State Key Laboratory of Food Science and Technology, Nanchang University, Nanchang 330047, China
| | - Yan Hong
- Jiangxi Institution for Drug Control, Nanchang 330024, China
| | - Yalan Huo
- Department of Medicinal Chemistry and Molecular Pharmacology, College of Pharmacy, Purdue University, 575 W Stadium Ave., West Lafayette, IN 47907, USA
| | - Lingling Peng
- State Key Laboratory of Food Science and Technology, Nanchang University, Nanchang 330047, China
| | - Huihui Lv
- State Key Laboratory of Food Science and Technology, Nanchang University, Nanchang 330047, China
| | - Jiahui Chen
- State Key Laboratory of Food Science and Technology, Nanchang University, Nanchang 330047, China
| | - Zhihua Wu
- State Key Laboratory of Food Science and Technology, Nanchang University, Nanchang 330047, China
- Jiangxi-OAI Joint Research Institute, Nanchang University, Nanchang 330047, China
| | - Cuixiang Wan
- State Key Laboratory of Food Science and Technology, Nanchang University, Nanchang 330047, China
- Jiangxi-OAI Joint Research Institute, Nanchang University, Nanchang 330047, China
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Gupta D, Sonawane A. Heart-leaved Moonseed- Innocuous or Baneful. J Clin Exp Hepatol 2022; 12:254-255. [PMID: 35068811 PMCID: PMC8766696 DOI: 10.1016/j.jceh.2021.08.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 08/22/2021] [Indexed: 01/03/2023] Open
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Balkrishna A, Bhattacharya K, Sinha S, Dev R, Srivastava J, Singh P, Haldar S, Varshney A. Apparent Hepatotoxicity of Giloy ( Tinospora cordifolia): Far From What Meets the Eyes. J Clin Exp Hepatol 2022; 12:239-240. [PMID: 35068809 PMCID: PMC8766691 DOI: 10.1016/j.jceh.2021.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/06/2021] [Indexed: 02/07/2023] Open
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Björnsson ES, Navarro VJ, Chalasani N. Liver Injury Following Tinospora Cordifolia Consumption: Drug-Induced AIH, or de novo AIH? J Clin Exp Hepatol 2022; 12:6-9. [PMID: 35068778 PMCID: PMC8766689 DOI: 10.1016/j.jceh.2021.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Einar S Björnsson
- Department of Gastroenterology, Landspitali University Hospital, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Victor J Navarro
- Department of Medicine, Einstein Health Care Network, Jefferson Health, Philadelphia, PA, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indianapolis, IN, USA
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Rastogi S, Pandey P. Idiosyncratic adversity reported after oral consumption of an ayurvedic formulation containing bhallataka (Semecarpus anacardium): A case report. J Ayurveda Integr Med 2022; 13:100635. [PMID: 36462347 PMCID: PMC9713265 DOI: 10.1016/j.jaim.2022.100635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 12/05/2022] Open
Abstract
Drugs associated adversities are common in health care practice. These adversities are often associated with the dose-related, time-related and methods of drug intake and their rationality in a given condition but can also be unrelated to either of these causes. Such unpredictable drug reactions are highly important from the perspective of safe use of a drug and to prevent complications from any such adversity which is relatively uncommon. The case reported here is a likely case of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) like idiosyncratic adversity after oral consumption of an ayurvedic formulation containing Bhallataka (Semecarpus anacardium). DRESS is found associated with many other classes of drugs but its association with ayurvedic drug has not yet been reported. Upon Naranjo probability scale the event scored 6, putting it into the category of probable drug related adversity. This report widens our understanding towards the possibility of delayed and idiosyncratic drug adversities upon the consumption of certain ayurvedic drugs.
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Tinospora Cordifolia (Giloy) and Autoimmune-like Liver Injury - A Classic Case of Primum Non Nocere, "First, Do No Harm". J Clin Exp Hepatol 2022; 12:245-246. [PMID: 34511809 PMCID: PMC8416289 DOI: 10.1016/j.jceh.2021.08.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 08/30/2021] [Indexed: 12/12/2022] Open
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Woo SM, Davis WD, Aggarwal S, Clinton JW, Kiparizoska S, Lewis JH. Herbal and dietary supplement induced liver injury: Highlights from the recent literature. World J Hepatol 2021; 13:1019-1041. [PMID: 34630872 PMCID: PMC8473494 DOI: 10.4254/wjh.v13.i9.1019] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/08/2021] [Accepted: 08/09/2021] [Indexed: 02/06/2023] Open
Abstract
Herbal-induced liver injury (HILI) is an important and increasingly concerning cause of liver toxicity, and this study presents recent updates to the literature. An extensive literature review was conducted encompassing September 2019 through March 2021. Studies with clinically significant findings were analyzed and included in this review. We emphasized those studies that provided a causality assessment methodology, such as Roussel Uclaf Causality Assessment Method scores. Our review includes reports of individual herbals, including Garcinia cambogia, green tea extract, kratom as well as classes such as performance enhancing supplements, Traditional Chinese medicine, Ayurvedic medicine and herbal contamination. Newly described herbals include ashwagandha, boldo, skyfruit, and 'Thermo gun'. Several studies discussing data from national registries, including the United States Drug-Induced Liver Injury (DILI) Network, Spanish DILI Registry, and Latin American DILI Network were incorporated. There has also been a continued interest in hepatoprotection, with promising use of herbals to counter hepatotoxicity from anti-tubercular medications. We also elucidated the current legal conversation surrounding use of herbals by presenting updates from the Federal Drug Administration. The highlights of the literature over the past year indicate interest in HILI that will continue as the supplement industry in the United States grows.
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Affiliation(s)
- Stephanie M Woo
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC 20007, United States.
| | - William D Davis
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC 20007, United States
| | - Soorya Aggarwal
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC 20007, United States
| | - Joseph W Clinton
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC 20007, United States
| | - Sara Kiparizoska
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC 20007, United States
| | - James H Lewis
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC 20007, United States
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12
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Acharya SK. Acute Liver Failure: Indian Perspective. Clin Liver Dis (Hoboken) 2021; 18:143-149. [PMID: 34691401 PMCID: PMC8518349 DOI: 10.1002/cld.1135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/26/2021] [Accepted: 05/05/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
- Subrat Kumar Acharya
- Pro chancellorKIIT UniversityBhubaneswarIndia,Emeritus Professor in GastroenterologyAll India Institute of Medical SciencesNew DelhiIndia
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Yu J, Yang M, Han J, Pang X. Fungal and mycotoxin occurrence, affecting factors, and prevention in herbal medicines: a review. TOXIN REV 2021. [DOI: 10.1080/15569543.2021.1925696] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Jingsheng Yu
- Key Lab of Chinese Medicine Resources Conservation, State Administration of Traditional Chinese Medicine of the People’s Republic of China, Institute of Medicinal Plant Development, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Engineering Research Center of Chinese Medicine Resource, Ministry of Education, Beijing, China
| | - Meihua Yang
- Key Lab of Chinese Medicine Resources Conservation, State Administration of Traditional Chinese Medicine of the People’s Republic of China, Institute of Medicinal Plant Development, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jianping Han
- Key Lab of Chinese Medicine Resources Conservation, State Administration of Traditional Chinese Medicine of the People’s Republic of China, Institute of Medicinal Plant Development, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Engineering Research Center of Chinese Medicine Resource, Ministry of Education, Beijing, China
| | - Xiaohui Pang
- Key Lab of Chinese Medicine Resources Conservation, State Administration of Traditional Chinese Medicine of the People’s Republic of China, Institute of Medicinal Plant Development, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Engineering Research Center of Chinese Medicine Resource, Ministry of Education, Beijing, China
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14
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Nagral A, Adhyaru K, Rudra OS, Gharat A, Bhandare S. Herbal Immune Booster-Induced Liver Injury in the COVID-19 Pandemic - A Case Series. J Clin Exp Hepatol 2021; 11:732-738. [PMID: 34230786 PMCID: PMC8252698 DOI: 10.1016/j.jceh.2021.06.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/24/2021] [Indexed: 02/08/2023] Open
Abstract
The COVID-19 pandemic has resulted in widespread use of complementary and alternative medicines. Tinospora cordifolia is a widely grown shrub which has been commonly used in India's traditional system of Ayurveda for its immune booster properties and has been extensively used as prophylaxis against COVID-19. Six patients (4 women, 2 men) with a median (IQR) age of 55 years (45-56) and with an history of Tinospora cordifolia consumption presented with symptoms of acute hepatitis during the study period of 4 months in the COVID-19 pandemic. The median (IQR) duration of Tinospora cordifolia consumption was 90 days (21-210). The median (IQR) peak bilirubin and AST were 17.5 mg/dl (12.2-24.9) and 1350 IU/ml (1099-1773), respectively. The patients had either a definite (n = 4) or probable (n = 2) revised autoimmune hepatitis score with an autoimmune pattern of drug-induced liver injury on biopsy. Four of these patients (all women) had underlying silent chronic liver disease of possible autoimmune etiology associated with other autoimmune diseases - hypothyroidism and type 2 diabetes mellitus. One of the three patients treated with steroids decompensated on steroid tapering. The other five patients had resolution of symptoms, liver profile, and autoimmune serological markers on drug withdrawal/continuing steroid treatment. The median (IQR) time to resolution from discontinuing the herb was 86.5 days (53-111). Tinospora cordifolia consumption seems to induce an autoimmune-like hepatitis or unmask an underlying autoimmune chronic liver disease, which may support its immune stimulant mechanism. However, the same mechanism can cause significant liver toxicity, and we recommend that caution be exercised in the use of this herb, especially in those predisposed to autoimmune disorders. Besides, in patients presenting with acute hepatitis, even in the presence of autoimmune markers, a detailed complementary and alternative medicine history needs to be elicited.
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Key Words
- AIH, Autoimmune hepatitis
- ALT, Alanine Transaminase
- ASMA, Anti-Smooth Muscle Antibody
- AST, Aspartate Transaminase
- CAM, Complementary and Alternative Medicines
- COVID-19, Coronavirus Disease of 2019
- DILI, Drug-Induced Liver Injury
- Giloy
- IQR, Inter Quartile Range
- IgG, Immunoglobulin G
- LFT, Liver Function Tests
- RUCAM, Roussel Uclaf Causality Assessment Method
- SMT, Standard medical treatment
- TC, Tinospora cordifolia
- ULN, Upper Limit of Normal
- USG, Ultrasonography
- drug induced liver injury
- drug-induced autoimmune hepatitis
- herb induced liver injury
- tinospora cordifolia
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Affiliation(s)
- Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, India,Department of Gastroenterology, Apollo Hospital, Navi Mumbai, India,Address for correspondence. Aabha Nagral, 7, Snehasagar, Prabhanagar, Prabhadevi, Mumbai, 400025, India. Tel.: +919820156834.
| | - Kunal Adhyaru
- Department of Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, India
| | - Omkar S. Rudra
- Department of Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, India
| | - Amit Gharat
- Department of Gastroenterology, Apollo Hospital, Navi Mumbai, India
| | - Sonal Bhandare
- Department of Pathology, Jaslok Hospital and Research Centre, Mumbai, India
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