Case Report
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Dec 27, 2023; 15(12): 1333-1337
Published online Dec 27, 2023. doi: 10.4254/wjh.v15.i12.1333
Drug induced autoimmune hepatitis: An unfortunate case of herbal toxicity from Skullcap supplement: A case report
Nimish Thakral, Venkata Rajesh Konjeti, Fady William Salama
Nimish Thakral, Venkata Rajesh Konjeti, Fady William Salama, Department of Digestive Diseases and Nutrition, University of Kentucky, Lexington, KY 40536, United States
Author contributions: Thakral N, Konjeti VR, and Salama F were involved in patient care and drafting of the manuscript.
Informed consent statement: Our institution does not require separate consent for case reports.
Conflict-of-interest statement: There are no conflicts of interest associated with our report.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Noncommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Nimish Thakral, MBBS, MD, Assistant Professor, Department of Digestive Diseases and Nutrition, University of Kentucky, 800 Rose St., Lexington, KY 40536, United States. thakral.nimish@uky.edu
Received: July 16, 2023
Peer-review started: July 16, 2023
First decision: August 14, 2023
Revised: September 14, 2023
Accepted: November 24, 2023
Article in press: November 24, 2023
Published online: December 27, 2023
Processing time: 161 Days and 9.7 Hours
Abstract
BACKGROUND

The surge in traditional herbal dietary supplement (HDS) popularity has led to increased drug-induced liver injuries (DILI). Despite lacking evidence of efficacy and being prohibited from making medical claims, their acceptance has risen over sevenfold in the last two decades, with roughly 25% of United States (US) adults using these supplements monthly. An estimated 23000 emergency room visits annually in the US are linked to HDS side effects. NIH-funded research suggests HDS contribute to 7-20% of DILI cases, with similar trends in Europe—Spain reporting 2% and Iceland up to 16%. Patients with acute liver failure from HDS undergo liver transplantation more frequently than those from prescription medicines. Here we describe a case of drug-induced autoimmune hepatitis due to Skullcap supplements, this association appears to be the first documented instance in literature.

CASE SUMMARY

A middle-aged Caucasian woman, previously healthy, presented with sudden jaundice. Four months earlier, her liver enzymes were normal. She mentioned recent use of Skullcap mushroom supplements. Tests for chronic liver disease were negative. The first liver biopsy indicated severe resolving drug-induced liver injury. Despite treatment, she was readmitted due to worsening jaundice. Follow-up tests raised concerns about autoimmune hepatitis. A subsequent biopsy confirmed this diagnosis. The patient responded as expected to stopping the medication with improvement in liver enzymes.

CONCLUSION

This scenario highlights an uncommon instance of DILI caused by Skullcap supplements. It's crucial for hepatologists to recognize this connection due to the increasing prevalence of herbal supplements.

Keywords: Drug induced liver injury; drug induced autoimmune hepatitis; herbal supplement; Skullcap; Case report

Core Tip: This case report highlights a rare presentation of drug induced liver injury from Skullcap supplement usage. While Chinese Skullcap (Scutellaria baicalensis) has been associated with a mixed hepatocellular and cholestatic picture of drug-induced liver injuries, the association of North American Skullcap is not as robust. Here we present a case of drug induced autoimmune hepatitis from North American Skullcap supplement use. Hepatologists must be aware of this association of rare histopathological presentation.