Introduction: Ashwagandha is a derivative of the medicinal plant Withania somnifera. It has been used for centuries as a tonic to increase energy, reduce fatigue and as anti-aging in Ayurvedic medicine. Herbal medicines and dietary supplements (HDS) are categorized as food by the FDA and, unlike prescription medicines, are presumed to be safe unless otherwise reported. However, a recent case series has implicated this herb to cause clinically apparent liver injury. This case illustrates the hepatotoxic potential of ashwagandha.
Case Description/Methods: A 20-year-old healthy college student presented to our ER with complaints of yellowish discoloration of skin and worsening abdominal pain for 3 days. The discoloration was initially noted in his eyes, associated with excessive itching of skin but no stool changes. He also had right upper quadrant abdominal pain, 6/10 in intensity, without any associated aggravating or relieving factors. He denied recent travel, alcohol or drug consumption and his last sexual encounter was 4 months ago. His physical examination was significant for a normal BMI, icteric sclera, soft and non-tender abdomen. Initial labs showed AST of 659 and ALT of 415 and direct bilirubinemia of 8.6. A thorough autoimmune, infective hepatitis panel and hemolytic anemia work up was negative. USG and CT abdomen/pelvis showed no abnormalities. On further questioning he endorsed consuming over the counter (OTC) Ashwagandha 450mg every day for the past 30 days to “calm his nerves”. Over the course of his hospitalization, he symptomatically improved with down trending liver enzymes and bilirubin. He was advised to avoid ashwagandha containing supplements in the future. Post-discharge 3 week follow up showed a normal hepatic function test.
Discussion: Withanolides are the active components of Ashwagandha. The liver injury presents 2 to 12 weeks after ingestion with a cholestatic or mixed pattern of injury, jaundice and pruritus. Jaundice tends to be a dominant feature but ultimately resolves after discontinuation of the offending drug without fatalities or chronic injury. Biopsy can be considered if no clinical improvement to evaluate for uncommon etiologies. Benefit of ursodeoxycholeic acid use in drug induced liver injury remains controversial. OTC medication and herbal supplements have been associated with liver injury and it is important to obtain a thorough history in a patient with elevated transaminases.
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