Northwell Health, Lenox Hill Hospital New York, NY
Introduction: Herbal supplements (HS) are being widely utilized for the self-treatment of various medical conditions. Despite their growing popularity, HS utilization has resulted in drug induced liver injury (DILI) as well as acute liver failure (ALF). Lesser Celandine, also known as pilewort, is a topical and ingestible HS native to Northern Africa, used for the treatment of hemorrhoids. Here, we present a case of severe DILI secondary to this rarely reported agent.
Case Description/Methods: A 34-year-old female with hemorrhoids and fibroids presented after noticing yellowing of her eyes for one week. She denied associated fevers, nausea, vomiting, abdominal pain, toxic habits, personal or familial history of autoimmune illnesses or malignancy. She traveled to Ghana 10 months prior, at which time she self-initiated treatment with the HS known as pilewort for her hemorrhoids. Physical exam demonstrated enlarged abdominal girth, scleral icterus, and was negative for asterixis. Laboratory studies (Table 1) revealed severe hepatocellular injury and hyperbilirubinemia. Autoimmune and viral hepatitis serologies were negative. CT abdomen and pelvis revealed no hepatosplenomegaly, no biliary ductal dilation, and an enlarged leiomyomatous uterus. Non-acetaminophen N-Acetylcysteine protocol was initiated with observed improvement in her liver enzymes. She subsequently underwent a liver biopsy, which exhibited confluent pericentral necroinflammation, apoptotic hepatocytes, and no evidence of steatosis or fibrosis, consistent with DILI. The patient ultimately left against medical advice and was lost to follow up.
Discussion: DILI comprises up to 50% of ALF cases in the United States, with a higher incidence in the Eastern world secondary to increased use of HS. Identification remains a challenge, as presentation is highly variable. Diagnosis is based on exclusion with workup largely dependent on pattern of liver injury. As in our case, in those with hepatocellular injury, ischemia, viral, autoimmune and toxic etiologies must be ruled out. A comprehensive medication reconciliation is essential, including a detailed inquiry on the use of herbal medicines, especially in cases of unexplained liver injury. Pilewort DILI is reported once in the literature since first described in 1904. We present this case to raise awareness of the hepatotoxic properties of pilewort.
