Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Woodbury, New York
Introduction: Drug induced liver injury (DILI), the most common reason for drug withdrawal, accounts for approximately 10% of all cases of acute hepatitis. Herbal and dietary supplements (HDS) have been indicated in approximately 15 to 20% of all reported DILI cases. Turmeric, a very popular HDS, is an herb derived from a Southeast Asian plant, Curcuma longa. It has been widely used for its anti-inflammatory properties to treat many conditions and is considered safe at appropriate doses
Case Description/Methods: A 65 year-old female was referred for jaundice associated with fatigue and pruritis. Her medical history was significant for hyperlipidemia and arthritis. Her medications included aspirin 81 mg, rosuvastatin 5 mg, niacinamide 500 mg, and various vitamins and supplements, including 500 mg per day of Turmeric. She denied using alcohol, IV drugs, or acetaminophen. Physical exam was unremarkable, except for diffuse jaundice and scleral icterus. Blood work revealed an AST of 2,460 U/L, ALT of 2,464 U/L, total bilirubin of 14.9 mg/dL, and alkaline phosphatase of 250 U/L. An acute viral hepatitis panel and CBC were within normal limits. Further labs were unremarkable, including negative serologies for autoimmune hepatitis. An MRI of her abdomen revealed cholelithiasis and periportal edema, with no evidence of cholecystitis, choledocholithiasis, or biliary ductal dilatation. At onset of symptoms, the patient had stopped all her medications and supplements. Within 3 months, the jaundice had resolved, and liver enzymes returned to normal. However, 2 months later the patient returned with diffuse, yet milder jaundice. Labs again noted markedly elevated aminotransferases and total bilirubin. Other liver disease labs, including autoimmune serologies, remained negative. She reported that while she remained off her statin, she had restarted Turmeric 3 weeks prior. A liver biopsy revealed pronounced interface chronic hepatitis with lymphocytes and plasma cells, extending into the lobule with Kupffer cell activation. The Turmeric was again discontinued. The jaundice subsequently resolved, and liver enzymes normalized within 6 weeks.
Discussion: This is a case of Turmeric induced liver injury with recurrence after re-challenge. While Turmeric is considered a safe HDS at appropriate doses, it must be considered as a primary cause of DILI and acute hepatitis. While most patients tolerate this HDS without incident, more research is needed to help identify individuals who are potentially at risk for adverse events.
