Medical University of South Carolina Charleston, SC
Serena Khaleghi, MD, Jake Wilson, MD, MS Medical University of South Carolina, Charleston, SC Introduction: 20% of all drug induced liver injuries (DILI) occur secondary to herbal supplements. Diagnosis can be challenging due to the lack of regulation, improper labeling, and inconsistent ingredient concentrations. Product inconsistency leads to varying clinical presentations and severity of liver injury, ultimately delaying diagnosis and treatment.
Case Description/
Methods: The patient is a 70 year old male who presented with abdominal pain and fatigue. Labs were notable for an AST of 1472, ALT of 1315, total bilirubin (tbili) of 2.3, ALP of 1200, Hgb of 18.7, ferritin of 37,000, and percent iron saturation of 94. He endorsed recent initiation of a supplement marked as a testosterone booster that utilizes ashwagandha, Eurycoma longifolia and ginseng. He also endorsed drinking two cups of vodka per day.
Initial differential included hemophagocytic lymphohistiocytosis (HLH), hereditary hemochromatosis (HH), underlying infiltrative disease, malignancy, and DILI. MRCP showed iron deposits in the liver, but a trial of deferoxamine infusions did not yield improvement. Labs peaked with an AST of 2,939, ALT of 1,945, tbili of 34, ferritin of 66,000, INR of 1.1, and ammonia of 105. Liver biopsy demonstrated acute and chronic hepatitis with hepatocyte ballooning and necrosis, findings consistent with DILI. The previously mentioned supplement was implicated as the most likely cause and he was started on prednisone 30 mg/day. He developed subsequent improvement in liver function tests (LFT) with an AST of 131, ALT of 204, ALP of 159, and tbili of 10.9. Discussion: As in our patient, the degree of LFT abnormality may be profound and masquerade as other diagnoses. Our initial differential included HH and HLH, both of which can present with elevated ferritin, hepatic involvement, and a subsequent rise in LFTs. Additionally, there have been cases of DILI that masked underlying HH, further complicating the clinical picture.
This patient’s possible underlying HH likely augmented the severity of DILI secondary to ashwagandha. Underlying liver disease is associated with both a higher likelihood of DILI and worse outcomes. Our patient did not ultimately develop liver failure. However, there are case reports of DILI secondary to herbal / dietary supplements resulting in need for liver transplant, especially in patients with preexisting liver disease. This emphasizes the need for recognizing the role herbal supplements play in DILI, allowing for earlier diagnosis and treatment.
Disclosures: Serena Khaleghi indicated no relevant financial relationships. Jake Wilson indicated no relevant financial relationships.
Serena Khaleghi, MD, Jake Wilson, MD, MS. P1804 - Beyond the Label: Hepatotoxicity Following the Use of a Testosterone-Boosting Supplement, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
