Khat (Catha Edulis) as a possible cause of autoimmune hepatitis

Chronic hepatitis B virus infection in Eastern Ethiopia: Clinical characteristics and determinants of cirrhosis

BACKGROUND

Chronic hepatitis B (CHB) virus infection is a major cause of liver-associated morbidity and mortality, particularly in low-income countries. A better understanding of the epidemiological, clinical, and virological characteristics of CHB will guide appropriate treatment strategies and improve the control and management of CHB in Ethiopia.

AIM

To investigate the characteristics of CHB in Eastern Ethiopia and assess the efficacy and safety of antiviral treatment.

METHODS

This cohort study included 193 adults who were human immunodeficiency virus-negative with CHB between June 2016 and December 2019. Baseline assessments included chemistry, serologic, and viral markers. χ 2 tests, Mann-Whitney U tests, and logistic regression analyses were used to identify the determinants of cirrhosis. Tenofovir disoproxil fumarate (TDF) was initiated using treatment criteria from the Ethiopian CHB pilot program.

RESULTS

A total of 132 patients (68.4%) were men, with a median age of 30 years [interquartile range (IQR): 24-38]. At enrollment, 60 (31.1%) patients had cirrhosis, of whom 35 (58.3%) had decompensated cirrhosis. Khat use, hepatitis B envelope antigen positivity, and a high viral load were independently associated with cirrhosis. Additionally, 66 patients (33.4%) fulfilled the treatment criteria and 59 (30.6%) started TDF. Among 29 patients who completed 24 months of treatment, the median aspartate aminotransferase to platelet ratio index declined from 1.54 (IQR: 0.66-2.91) to 1.10 (IQR: 0.75-2.53) (P = 0.002), and viral suppression was achieved in 80.9% and 100% of patients after 12 months and 24 months of treatment, respectively. Among the treated patients, 12 (20.3%) died within the first 6 months of treatment, of whom 8 had decompensated cirrhosis.

CONCLUSION

This study highlights the high prevalence of cirrhosis, initial mortality, and the efficacy of TDF treatment. Scaling up measures to prevent and control CHB infections in Ethiopia is crucial.

Different Course And Management of Khat-Induced Autoimmune Hepatitis: Report On Three Cases

Khat is a plant that is commonly used for its stimulating effects and is chewed for its psychoactive properties. It creates feelings of euphoria that are similar to when taking amphetamines. There is an association between khat and liver injury, but the mechanism is not well known. We present three cases of khat-induced liver injury. All cases have elevated IgG and either positive antinuclear antibodies (ANA) or anti-smooth muscle antibody (ASMA); each case has a different course and requires different management. One case improved only by stopping khat, one required a short course of steroids and the last case required treatment such as that for autoimmune hepatitis (AIH).

LEARNING POINTS

This is the first report on different courses and management of khat-induced hepatitis.Although khat-induced AIH is rare, early detection and management have a significant effect on disease remission.Further studies are needed to evaluate the mechanism of how khat-induced autoimmune hepatitis as it is not well understood.

Recreational Drugs and the Risk of Hepatocellular Carcinoma

Recreational or aesthetic drug use is a distinctive behavior of humans, principally attested in the last century. It is known that recreational and illegal drugs are major contributors to the universal morbidity rate worldwide. Many of these substances have a well-established hepatotoxic potential, causing acute or chronic liver injury, liver fibrosis and cirrhosis, but their implications for hepatocellular carcinoma or other varieties of liver tumors are little known. In this article, we perform an extensive literature review, aiming to provide updated information about recreational drug use and the risk of developing liver tumors. Khat use and pyrrolizidine alkaloid consumption (present in some natural plants) have been linked to liver cirrhosis. Kava intake is associated with different liver tumors in animal models but not in humans. Cannabis' potential to accelerate liver fibrosis in chronic hepatitis is controversial according to the existing data. Cigarette smoking is an important contributor to hepatocellular carcinoma, and anabolic androgen steroids are well-defined causes of a variety of liver cancers and other hepatic tumors. Long-term follow-up studies of subjects who have developed injuries in association with the use of recreational drugs are warranted so as to better define the risk of developing hepatocellular carcinoma in association with these substances and, thus, to implement health care policies to combat this preventable cause of cancer.

Progress and Research Trends on Catha edulis (Vahl) Endl. (Catha edulis): A Review and Bibliometric Analysis

Catha edulis (Vahl) Endl., known as Catha edulis or Khat is a traditional and regional plant for chewing, smoking and drinking, that has posed a worldwide public health problem due to its recent emerging abused consumption. In the face of the massive use of Catha edulis, we reviewed related publications to analyze the progress and research trends through bibliometric methods. After screening, a total of 514 scientific publications published from 1997 to 2020 were included by systematic retrieval from the Web of Science (WoS) database. According to further scientometric analysis, the annual number of publications output kept rising in most of the years. Ethiopia and the United States of America (USA) have been devoting significant contributions to the field. Though the research emphasis had been the chemical composition and pharmacological and toxicological effects for several years, the hot spots were transferred; the mechanism investigations of Catha edulis have been the focus in recent years, which might be continued in the future. Furthermore, co-operations of multi-disciplinary researchers are needed to minimize abuse harms and maximize the medicinal benefits of Catha edulis to human beings.

The impact of catha edulis (vahl) forssk. ex endl. (celestraceae) (khat) on pharmacokinetics of clinically used drugs

INTRODUCTION

Catha edulis (Vahl) Forssk. ex Endl. (Celestraceae) is used as a recreational drug on daily basis for its euphoric and psychostimulant effects. It is also chewed by individuals who are on medications, raising the possibility of drug-khat interaction. However, limited data are available in the literature, although clinically significant interactions are expected, as khat contains a complex mixture of pharmacologically active constituents.

AREAS COVERED

It provides an overview of the phytochemistry, pharmacokinetics, pharmacodynamics, and pharmacogenetics of khat based on the literature mined from PubMed, Google Scholar, and Cochrane databases. It also presents a detailed account of drug-khat interactions with specific examples and their clinical significance. The interactions mainly occur at the pharmacokinetics level and particular attention is paid for the phases of absorption and cytochrome P450 enzyme-mediated metabolism.

EXPERT OPINION

Despite the increasing trend of khat chewing with medications among the populace and the potential risk for the occurrence of clinically significant interactions, there is paucity of data in the literature demonstrating the magnitude of the risk. The available data, however, clearly demonstrate that the consequence of drug-khat interaction is dependent on genotype. Genotyping, where feasible, could be used to improve clinical outcome and minimize adverse reactions.

Acute Hepatitis in a Yemeni Immigrant Associated with Khat: A "Biological Amphetamine" Carried in Cultures

Viral infections, alcohol, hepatic steatosis, autoimmunity medications and herbal supplements are common etiologies of hepatitis. Khat (Catha Edulis) is a commonly used recreational substance in East African and Middle Eastern countries. Khat has been reported in the literature to be associated with hepatotoxicity, which can present in several forms, including chronic liver disease. The possible pathogenesis of liver injury could be secondary to biochemical components of Khat itself or additives such as pesticides or preservatives. An autoimmune mechanism of liver injury has also been postulated, supported by sparse evidence. We present a case of a Yemeni immigrant with acute hepatitis whose fear about social norms and breaching confidentiality made it challenging to identify Khat as being the underlying cause. A 34-year-old man from Yemen presented with right upper quadrant pain of one day duration. He had predominantly elevated transaminases with mild elevation in bilirubin. His investigations were negative for the viral, metabolic or biliary etiology. A persistent focus on clinical history and the well-established physician–patient relationship revealed a history of Khat use. The liver biopsy finding of lobular hepatitis was compatible with drug-induced liver injury and established the finding of Khat hepatotoxicity. Subsequently, the patient improved with conservative management.

Drug-Induced Liver Injury Caused by "Khat," an Herbal Stimulant

We describe a case of Catha edulis (Khat) drug-induced liver injury in a 28-year-old man from Yemen. The patient presented with jaundice, fatigue, and anorexia. Extensive workup, including liver biopsy, was performed. This is the first reported case in the United States without definite autoimmune hepatitis. Diagnosis requires high clinical suspicion and extensive workup. Increasing migration and differences in cultural practices lead to the need for an increased awareness of this type of cases, which is underreported.

Synthetic psychoactive cathinones: hypothermia and reduced lethality compared to methamphetamine and methylenedioxymethamphetamine

RATIONALE

Synthetic psychoactive cathinones (SPCs) are drugs with psychostimulant and entactogenic properties like methamphetamine (MA) and 3,4-methylenedioxymethamphetamine (MDMA). Despite clinical reports of human overdose, it remains to be determined if SPCs have greater propensity for adverse effects than MA or MDMA.

OBJECTIVES

To determine whether the SPCs cathinone (CAT), methcathinone (MCAT), mephedrone (MMC), and methylenedioxypyrovalerone (MDPV) have lower LD50 values than MA or MDMA.

METHODS

Male and female C57Bl/6J mice received single injections of one of 6 doses of a test drug (0-160 mg/kg IP). Temperature and behavioral observations were taken every 20 min for 2 h followed by euthanasia of surviving mice. Organs were weighed and evaluated for histopathological changes.

RESULTS

LD50 values for MA and MDMA, 84.5 and 100.9 mg/kg respectively, were similar to previous observations. The LD50 for MMC was 118.8 mg/kg, but limited lethality was observed for other SPCs (CAT, MCAT, MDPV), so LD50 values could not be calculated. For all drugs, death was associated with seizure, when it was observed. Rather than hyperthermia, dose-dependent hypothermia was observed for MMC, MDPV, CAT, and MCAT. Contrary to initial expectations, none of the SPCs studied here had LD50 values lower than MA or MDMA.

CONCLUSIONS

These data indicate that, under the conditions studied here: (1) SPCs exhibit less lethality than MA and MDMA; (2) SPCs impair thermoregulation; (3) effects of SPCs on temperature appear to be independent of effects on lethality.

High Seroprevalence of Autoantibodies Typical of Autoimmune Liver Disease in Eastern Ethiopia: Is Chewing of Khat (Catha edulis) a Triggering Factor?

BACKGROUND

Recent studies have identified chewing of khat (Catha edulis) as an independent risk factor for liver injury; however, the pathogenetic mechanism remains poorly understood. Case series have found markers of autoimmune hepatitis in patients with khat-related liver disease, suggesting that khat chewing might trigger an autoimmune response. The aims of the present study were (i) to assess the prevalence of autoantibodies typical for autoimmune liver diseases in a healthy population in Ethiopia and (ii) to explore the hypothesis that khat usage triggers autoimmunity.

METHODS

Consenting adults (≥18 years) without known autoimmune disease or manifest liver disease were included. One-hundred-and-sixty-nine individuals with current khat use were compared to 104 individuals who never used khat. Seroprevalence of antinuclear (ANA), antismooth muscle (SMA), and antimitochondrial antibodies (AMA) were determined and compared between the groups using logistic regression models to adjust for age and sex.

RESULTS

Overall, 2.6% of the study subjects were positive for ANA, 15.4% for SMA, and 25.6% for AMA. When comparing khat users to nonusers, ANA was detected in 4.1% vs. 0% (p=0.047), SMA in 16.0% vs. 14.4% (p=0.730), and AMA in 24.9% vs. 26.9% (p=0.704). ANA was excluded from multivariable analysis since there was no seropositive in the reference group. After adjusting for sex and age, no significant association between khat use and SMA or AMA was found.

CONCLUSIONS

No association between khat usage and the seropresence of SMA or AMA was found, weakening the hypothesis that khat-related liver injury is mediated through autoimmune mechanisms. However, the seroprevalences of AMA and SMA were strikingly high in this Ethiopian population compared to global estimates, suggesting that diagnostic algorithms for autoimmune liver diseases developed in Europe and North America might lead to misdiagnosis of patients on the African continent.

Khat chewing increases the risk for developing chronic liver disease: A hospital-based case-control study

The chewing of the leaves of Catha edulis (khat) has been implicated in the development of liver disease, but no controlled observations have been undertaken. The objective of the present study was to determine whether khat chewing is associated with development of chronic liver disease (CLD). A case-control study was conducted at two public hospitals in Harar, Ethiopia, between April 2015 and April 2016. A consecutive sample of 150 adult hospital attendees with CLD were included as cases, and 300 adult hospital attendees without clinical or laboratory evidence of CLD were included as controls. Khat consumption was quantified in "khat years"; 1 khat year was defined as daily use of 200 g of fresh khat for 1 year. A logistic regression model was used to control for confounders. There was a significant association between chewing khat and the risk for developing CLD (crude odds ratio, 2.64; 95% confidence interval [CI], 1.56-4.58). In men, this risk, following adjustment for age, alcohol use, and chronic hepatitis B/C infection, increased with increasing khat exposure; thus, compared to never users the adjusted odds ratios were for low khat exposure 3.58 (95% CI 1.05-12.21), moderate khat exposure 5.90 (95% CI 1.79-19.44), and high khat exposure 13.03 (95% CI 3.61-47.02). The findings were robust in a post hoc sensitivity analysis in which individuals with identifiable risk factors for CLD were excluded.

CONCLUSION

A significant association was observed between chewing khat and the risk for developing CLD, and in men the association was strong and dose-dependent, suggesting a causal relationship; as the prevalence of khat chewing is increasing worldwide, these findings have major public health implications. (Hepatology 2018;68:248-257).

Pharmacological and Toxicological Effects of Catha edulis F. (Khat)

Khat chewing is deeply rooted in the culture and tradition of communities in khat belt countries, and its consumption is spread to other countries through the suitcase trade. The aim of this article is to review current knowledge on the chemistry, social, pharmacology and toxicology of khat and its use. Khat produces effect invariably in every system, which is harmful or beneficial in some instances. Harmful effects are observed in heavy users, although firm evidence is lacking. Chewing khat acutely elicits states of euphoria, which is followed by low mood. Khat contains alkaloids with psychostimulant properties, but the effect cannot be totally explained by these alkaloids. It is also not clear whether the effect produced in some organs like liver could be attributed to khat or pesticides sprayed during farming. Although the evidence indicates that khat has adverse effects in most organs, our understanding of the complex interaction between use and effect is incomplete, and causal relationships have not yet been described. Moreover, khat has positioned itself well in the social, economic and political arena. Thus, a multidisciplinary research is required to understand the different dimensions and come up with ways that maximize the benefit while minimizing the risk. Copyright © 2017 John Wiley & Sons, Ltd.

Protective effects of green tea and its main constituents against natural and chemical toxins: A comprehensive review

Toxins are natural or chemical poisonous substances with severe side effects on health. Humans are generally exposed by widespread toxic contaminations via air, soil, water, food, fruits and vegetables. Determining a critical antidote agent with extensive effects on different toxins is an ultimate goal for all toxicologists. Traditional medicine is currently perceived as a safe and natural approach against toxins. In this regard, we focused on the protective effects of green tea (Camellia sinensis) and its main components such as catechin, epicatechin, epicatechin gallate, gallocatechin, epigallocatechin and epigallocatechin gallate as a principal source of antioxidants against both natural and chemical toxins. This literate review demonstrates that protective effects of green tea and its constituents were mainly attributed to their anti-oxidative, radical scavenging, chelating, anti-apoptotic properties and modulating inflammatory responses. Although, some studies reveal they have protective effects by increasing toxin metabolism and neutralizing PLA₂, proteases, hyaluronidase and l-amino acid oxidase enzymes.

Khat chewing and cirrhosis in Somaliland: Case series

BACKGROUND

Khat chewing is common especially among men in East Africa and Yemen. It is generally viewed by the populace as a benign social custom. Several studies of ethnic Somali immigrants to Western countries suggest an association between khat chewing and hepatotoxicity, but the risk of hepatotoxicity related to khat chewing within African settings is not documented.

AIM

To identify and describe liver disease without evidence of alcohol exposure or infectious etiology in khat chewers.

SETTINGS

A university-affiliated teaching hospital in Somaliland.

METHODS

Cases of cirrhosis of unknown cause were identified from the clinical practice of Al Hayatt Hospital in Borama, Somaliland, during 14 months beginning December 2012.

RESULTS

Eight Somali men aged 27-70 years living in Somaliland were identified with cirrhosis of otherwise unknown cause. All chewed khat habitually for many years (15-128 bundles per day times years of use). A liver biopsy of one man was consistent with khat hepatotoxicity. Four of the eight men died during the study period.

CONCLUSION

Khat chewing may be associated with health consequences including severe hepatotoxicity with cirrhosis.

To chew or not to chew: that's the question

A 25-year-old Somalian man was referred to the department of internal medicine because of nausea, vomiting and jaundice of recent onset. On physical examination, he was frankly icteric without clinical signs of chronic liver disease. Laboratory data showed evidence of acute hepatitis. Viral serologic tests for hepatitis A, B, C and E were negative. Antinuclear antibodies (ANA) were positive (titre 1 : 1280; speckled pattern, NV < 1 : 40) as well anti-actin antibodies (titre 75 UA, NV < 20). A liver biopsy was performed and showed a feature compatible with toxic hepatitis. On further questioning, the patient admitted to daily chew Khat when he was living in Somalia. We concluded to Khat-induced toxic hepatitis together with high-titre anti-nuclear antibody mimicking serologic patterns of auto-immune hepatitis.

Hepatotoxicity Induced by "the 3Ks": Kava, Kratom and Khat

The 3Ks (kava, kratom and khat) are herbals that can potentially induce liver injuries. On the one hand, growing controversial data have been reported about the hepatotoxicity of kratom, while, on the other hand, even though kava and khat hepatotoxicity has been investigated, the hepatotoxic effects are still not clear. Chronic recreational use of kratom has been associated with rare instances of acute liver injury. Several studies and case reports have suggested that khat is hepatotoxic, leading to deranged liver enzymes and also histopathological evidence of acute hepatocellular degeneration. Numerous reports of severe hepatotoxicity potentially induced by kava have also been highlighted, both in the USA and Europe. The aim of this review is to focus on the different patterns and the mechanisms of hepatotoxicity induced by “the 3Ks”, while trying to clarify the numerous aspects that still need to be addressed.

Khat-induced liver injuries: A report of two cases

Khat is consumed for recreational purposes in many countries, including Yemen, where >50% of adults chew khat leaves regularly. A wide spectrum of khat-induced liver injuries has been reported in the literature. Herein, we report two patients with khat-induced liver injury. Both patients clinically presented with acute hepatitis, one of whom showed radiological evidence of hepatic outflow obstruction. Based on the histological tests, both patients had acute hepatitis, which indicated drug-induced liver injury (DILI) on a background of chronic hepatitis and portal fibrosis; of the two, one presented with symptoms of immune-mediated liver injury.