Hepatotoxicity associated with Garcinia cambogia: A case report

Table 1 Laboratory testing done to investigate acute liver failure etiology

Laboratory test	Reference range	Results
Liver function tests
Alanine aminotransferase	15-41 U/L	981 (H)
Aspartate aminotransferase	3-34 U/L	1062 (H)
Alkaline phosphate	45-117 U/L	248 (H)
Total bilirubin	0.2-1.3 mg/dL	1.3 (N)
Conjugated bilirubin	0.0-0.30 mg/dL	0.73 (H)
Total Protein	6.3-8.2 g/dL	6.8 (N)
Albumin	3.5-5.0 g/dL	2.8 (L)
Ammonia level	0-32 μmol/L	44 (H)
Coagulation Studies
Prothrombin time	10-13.5 s	19.0 (H)
International normalized ration	0.8-1.2	1.6 (H)
Viral serologies
Hepatitis A, IgM	Nonreactive	Nonreactive
Hepatitis A, IgG	Nonreactive	Reactive
Hepatitis B, core IgM	Nonreactive	Nonreactive
Hepatitis B, surface antigen	Nonreactive	Nonreactive
Hepatitis C antibody	Nonreactive	Nonreactive
Human immunodeficiency virus 1 and 2 antibody/antigen	Nonreactive	Nonreactive
Herpes simplex virus 1 and 2 IgM	Negative	Negative
Cytomegalovirus, IgM	Negative	Negative
Cytomegalovirus, IgG	Negative	Negative
Epstein Barr virus, IgM	Negative	Negative
Parvovirus B19, IgM/IgG	Negative	Negative
Rapid plasma regain (RPR)	Nonreactive	Nonreactive
Influenza A, antigen	Negative	Negative
Influenza B, antigen	Negative	Positive
Autoimmune liver disease panel
Antinuclear antibody	Negative	Negative
Antinuclear antibody titer	< 1.0 U	0.6 (N)
Antismooth muscle antibody	Negative	Negative
Antimitochondrial antibody, M2	< 0.1 U	< 0.1 (N)
Toxicology studies
Acetaminophen level	10-30 mcg/ml	< 2
Ethanol level	0-3 mg/dL	< 3
Urine toxicology screen	Negative	Negative

H: High; N: Normal; L: Low.

Table 2 Case reports of hepatotoxicity related to non-Hydroxycut formulation of Garcinia cambogia since 2009

Case report	Year	Age	Sex	Duration of GC use	Clinical presentation	CIOSM/RUCAM score	Liver transplantation
Present case	2019	26	Female	28 d	Nausea, vomiting, abdominal pain, anorexia and myalgia	9	No
Sharma et al[15]	2018	57	Female	28 d	Vomiting and abdominal pain	11	No
Kothadia et al[14]	2018	36	Female	28 d	Fever, nausea, vomiting, abdominal pain, fatigue and jaundice	8	No
Lunsford et al[7]	2016	34	Male	150 d	Nausea, vomiting, abdominal pain and dark urine	NA	Yes
Smith et al[13]	2016	26	Male	7 d	Fatigue, icteric sclera and skin	6	Yes
Corey et al[12]	2016	52	Female	25 d	Fatigue, intermittent confusion and jaundice	7	Yes
Melendez-Rosado et al[11]	2015	42	Female	7 d	Nausea, abdominal pain, clamminess	NA	No
Lee et al[16]	2014	39	Female	2 d	Nausea, abdominal pain, anorexia, dyspepsia, fatigue and jaundice	9	No
Sharma et al[10]	2010	19	Male	NA	Fever, fatigue, myalgia, arthralgia, Nausea, Vomiting, abdominal pain and jaundice, erythematous skin rash lower extremities	7	No

GC: Garcinia cambogia; CIOMS: Council of International Organizations of Medical Sciences; RUCAM: Roussel Uclaf Causality Assessment Method; NA: Not-available.

Table 3 The Council of International Organizations of Medical Sciences and Roussel Uclaf Causality Assessment Method Scale

Criteria	Score
Time from drug intake until reaction onset
5-90 d	+2
< 5 or > 90 d	+1
Time from drug withdrawal until reaction onset
< 15 d	+1
> 15 d	0
Alcohol risk
Present	+1
Absent	0
Age
> 55 yr	+1
< 55 yr	0
Course of reaction
> 50% improvement within 8 d	+3
> 50% improvement within 30 d	+2
Worsening or < 50% improvement in 30 d	-1
Concomitant therapy
Time to onset incompatible	0
Time to onset compatible but with unknown reaction	-1
Time to onset compatible but known reaction Role proved in the case	-2 -3
None or information not available	0
Exclusion of non-drug related causes
Ruled out	+2
Possible or not investigated	0
Probable	-3
Previous information on hepatotoxicity
Reaction unknown	0
Reaction published but unlabeled	+1
Reaction labeled in the product’s characteristics	+2
Response to re-administration
Positive	+3
Compatible	+2
Negative	-2
Not available or not interpretable	0
Plasma concentration of drug known as toxic	+3
Validated laboratory test with high specificity, sensitivity, and predictive values positive	+3
Validated laboratory test with high specificity, sensitivity, and predictive values negative	-3
Interpretation of score for drug induced liver injury:
> 8 definite drug induced liver injury
6-8 probable drug induced liver injury
3-5 Possible drug induced liver injury
1-2 Unlikely drug induced liver injury
< 0 drug induced liver injury excluded