We present a case of acute fulminant liver failure from a liver detoxification tea. We present a 60-year-old female with weakness, lethargy, scleral icterus, jaundice, and worsening mental status. She drank herbal tea three times a day for 14 days prior to symptom development. Liver tests were elevated. Remaining laboratory tests and imaging were negative for other etiologies. An ultrasound-guided liver biopsy showed submassive necrosis. A literature search on the ingredients shows six ingredients as having hepatotoxic effects and remaining ingredients as having very sparse hepatoprotective data. Healthcare professionals should discuss herbal medication and tea use and report adverse effects.
The American Association for the Study of Liver Diseases (AASLD) defines acute fulminant liver failure as an acute deterioration of function resulting in altered mentation and coagulopathy without any known preexisting disease [
A 60-year-old female with past medical history of hypertension presented with new-onset generalized weakness and lethargy worsening over the past two weeks. She denied any fevers, chills, changes in stool, changes in mental status, sick contacts, or recent travel. Her past medical history was significantly only for obesity. Her social history included no tobacco use, frequent alcohol consumption (3 glasses of wine every night), no IV drug use, no acetaminophen use, and no high risk sexual activity. Her alcohol use has been stable since she started drinking ten years ago. Previous laboratory testing showed normal liver function. She was fully vaccinated with no history of hepatitis. Her only home medication was hydrochlorothiazide, which she had been taking for years. She had no preexisting liver disease with normal liver function tests prior to this admission. She reported drinking Yogi Detox herbal tea three times a day for 14 days prior to symptom development. As per the patient, she was consuming this tea as a cleanse.
Physical examination demonstrated a normotensive and afebrile patient in mild distress. the patient was jaundiced with scleral icterus. Examination demonstrated a soft and nondistended abdomen with moderate right upper quadrant tenderness. Mental status was intact on admission; however, on the ninth day of the admission she became lethargic and developed asterixis. Initial laboratory tests are depicted in Table
Hepatic function panel on day of admission, 1 week and 2 weeks later.
Laboratory testing | On admission | 1 week | 2 weeks |
---|---|---|---|
Aspartate aminotransferase (5–35 U/L) | 450 | 1864 | 51 |
Alanine aminotransferase (4–35 U/L) | 583 | 2162 | 82 |
Alkaline phosphatase (30–99 U/L) | 202 | 143 | 72 |
Total bilirubin (0.2–1.2 mg/dl) | 27 | 43 | 30 |
Direct bilirubin (0.01–0.19 mg/dl) | 20 | 33 | 21 |
INR (0.9–1.2) | 4 | 2.7 | 7.8 |
There was concern that the cause of her liver injury might have been due to her Yogi detox herbal tea consumption. Using the 2016 Roussel Uclaf Causality Assessment Method (RUCAM) score as highlighted in Table
Roussel Uclaf Causality Assessment Method, an assessment of the causality of drug-induced liver injury.
Items for mixed liver injury | Score in our patient |
---|---|
Time to onset from cessation of drug/herb: <15 days | +2 |
Course of ALT after cessation of drug/herb: decrease ≥ 50% within 180 days | +2 |
Risk factors: alcohol use (>2 drinks/d for women) and Age ≥ 55 | +1 |
Concomitant drug/herbs: none | 0 |
Alternative causes: all causes ruled out | +2 |
Previous hepatotoxicity of the drug/herb: reaction published but unlabeled | +1 |
Response to unintentional reexposure: none | 0 |
Total score | 8 |
The
US-guided liver biopsy showing submassive necrosis.
The prevalence of herbal supplementation intake has been increasing; however, their use is unregulated by the Food and Drug Administration and unsupervised by medical professionals [
18-ingredient list contained in the Yogi Detox Tea and the articles published in PubMed highlighting their hepatotoxicity.
Ingredient | Number of hepatotoxic articles/case reports |
---|---|
Sarsaparilla root | 0 |
Cinnamon bark | 1 [ |
Ginger root | 0 |
Licorice root | 0 |
Dandelion root | 0 |
Cardamom seed | 0 |
Clove bud | 0 |
Black pepper | 1 [ |
Juniper berry | 1 [ |
Long pepper berry | 0 |
Phellodendron bark | 0 |
Rhubarb root | 4 [ |
Skullcap root | 7 [ |
Coptis root | 0 |
Forsythia fruit | 0 |
Gardenia fruit | 7 [ |
Honeysuckle | 0 |
Winter melon | 0 |
Six ingredients had one or more published studies associating it with hepatotoxicity. Hepatic toxicity caused by Gardenia has been demonstrated to cause oxidative stress-induced hepatocyte necrosis and apoptosis in murine models. Seven different articles attributed Gardenia’s component geniposide to its hepatotoxic effect [
While evidence suggests that the patient’s acute change is associated with tea consumption, the exact toxicity-inducing agent of this tea is unclear. Preexisting alcohol consumption in combination with the herbal supplementation may have hastened the progression of hepatotoxicity. In addition to the 19 ingredients, herbal products are contaminated with other toxins or added adulterants that are not advertised on the packaging. In addition, ingestion of multiple substances may increase the risk of hepatotoxicity. This “cluster” effect of herbal supplements has not been elucidated in the literature; however, it has been known that risk factors such as alcohol ingestion are susceptible to drug toxicity from alterations in drug metabolism. Regardless, herbal tea consumption must be monitored by healthcare professionals, and any side effects should be reported to specific organizations in order to take regulatory measures and control usage of such products.
Informed consent was obtained from the patient involved.
The author guarantor is Keerthana Kesavarapu. The remaining authors aided in caring for and editing the content of this case report. An earlier version of this work was presented as a poster at the Annual Scientific Meeting of the American College of Gastroenterology being held October 14–19, 2016.
The authors declare that there are no conflicts of interest regarding the publication of this paper.