P4837 - A Case of Drug Induced Liver Injury: Irish Moss vs Bladderwrack vs Chaparral

Saigopal R. Gujjula, MD¹, Francis Gacek, DO¹, Richie Dubey, MD¹, Sweta Lohani, MBBS, MD¹, Camelia Ciobanu, MD¹, Ali Wakil, MD¹, Jeeva Jaganathan, MD¹, Amr Dokmak, MD¹, Arnold N. Forlemu, MD, MPH², Ying Xian Liu, MD¹, Mohammad Nawaz, MD^1
1Brooklyn Hospital Center, Brooklyn, NY; ²Brooklyn Hospital Center, Athens, GA

Introduction: Drug induced liver injury is a common phenomenon, however, isolating for inciting substances can become challenging. Hepatotoxic agents are commonly studied and disclosed upon distribution. Nonetheless, herbal supplements which lack Food and Drug Administration approval are consumed and associated with unforeseen hepatotoxic effects.

Case Description/Methods: A 52 year old male with no past medical history presented to the emergency department with sole jaundice of sclera and oral mucosa. Patient endorsed consumption of irish moss, bladderwrack and chaparral for four weeks and affirmed ingestion of 12 oz of distilled spirit regularly on both weekend days. He denied travel, insect bites, or workplace exposure to chemicals. Patient was afebrile, and hemodynamically stable. Initial labs showed: total bilirubin: 14.1mg/dL, direct bilirubin: 10.3mg/dL, AST: >717U/L, ALT: 2070U/L,PT: 11.9, aPTT: 29.6, INR:1.0. R factor: 43.0 indicating hepatocellular injury. Acetylsalicylic acid, alcohol, acetaminophen, antinuclear antibody, anti-smooth muscle antibody, alpha 1 antitrypsin, hepatitis A, hepatitis B and hepatitis C were negative. Magnetic resonance imaging / magnetic resonance cholangiopancreatography showed no biliary duct dilatation, cholelithiasis or choledocholithiasis. Patient was immediately started on a 72 hour n-acetylcysteine protocol and prompt cessation of supplements and alcohol were advised. Hepatic function panel was trended (Table 1). A liver biopsy was performed on day 7 which showed mild portal chronic lymphocytic inflammation, minimal microvesicular steatosis, interface hepatitis, ballooning degeneration of hepatocytes, and mild portal fibrosis. No cholestasis was seen. Trichrome stain revealed mild fibrosis (1/4), reticulin stain revealed hepatocyte regeneration, iron stain and pas-d stain were negative (Figure 1). Patient was discharged once liver enzymes showed stable decline.

Discussion: Extreme elevations of AST and ALT in line with patient's supplement consumption clearly point towards a differential of drug induced liver injury. Alcohol induced liver injury was ruled out due to the degree of liver enzyme rise. The patient’s supplements included irish moss (chondrus crispus), bladderwrack (fucus vesiculosus) and chaparral (larrea tridentate). Upon discontinuation of supplements, liver enzymes declined. This case validates the need for further inquiry and regulation of herbal supplements.



Disclosures:


Saigopal R. Gujjula, MD¹, Francis Gacek, DO¹, Richie Dubey, MD¹, Sweta Lohani, MBBS, MD¹, Camelia Ciobanu, MD¹, Ali Wakil, MD¹, Jeeva Jaganathan, MD¹, Amr Dokmak, MD¹, Arnold N. Forlemu, MD, MPH², Ying Xian Liu, MD¹, Mohammad Nawaz, MD¹. P4837 - A Case of Drug Induced Liver Injury: Irish Moss vs Bladderwrack vs Chaparral, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.