Acute liver failure caused by alkaloids from traditional Chinese medicine: A case report

Table 1 Laboratory values and immunosuppression (operation date: October 30, 2024)

Laboratory tests	Item	POD 0	POD 1	POD 7	POD 14
Blood test	WBC (109/L)	14.23	10.51	7.71	8.00
	RBC (109/L)	1.89	3.20	2.80	2.63
	Hb (g/L)	65.00	101.00	90.00	117.00
	PLT (109/L)	51.00	28.00	53.00	125.00
Biochemistry	ALT (IU/L)	62.00	545.00	61.30	76.80
	AST (IU/L)	116.00	642.20	108.70	82.70
	ALP (IU/L)	96.00	156.00	270.00	202.00
	γ-GT (IU/L)	25.00	211.00	253.20	213.8
	TBIL (μmol/L)	527.10	183.60	314.20	107.1
	DBIL (μmol/L)	166.40	136.10	303.80	85.00
	ALB (g/L)	36.30	36.20	43.00	46.9
	BUN (mmol/L)	8.20	54.00	52.00	53.00
	CREA (μmol/L)	43.00	69.67	29.42	31.66
	Na (mmol/L)	138.00	136.00	138.00	136.00
Coagulation	PT (seconds)	45.28	13.10	14.70	13.30
	INR	4.13	1.13	1.18	1.03
	APTT (seconds)	86.01	27.90	29.90	35.70
	FIB (g/L)	0.47	2.30	3.40	3.57
	TT (seconds)	32.31	18.00	15.10	15.50
Immunosuppressants	Tacrolimus (mg)	-	-	7.26	4.99

POD: Postoperation day; WBC: White blood cell; RBC: Red blood cell; Hb: Hemoglobin; PLT: Platelet; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; ALP: Alkaline phosphatase; γ-GT: Gamma-glutamyltransferase; TBIL: Total bilirubin; DBIL: Direct bilirubin; ALB: Albumin; BUN: Blood urea nitrogen; CREA: Creatinine; Na: Sodium; PT: Prothrombin time; INR: International normalized ratio; APTT: Activated partial thromboplastin time; FIB: Fibrinogen; TT: Thrombin time.

Table 2 Major components of the traditional Chinese medicine prescription and their primary effects/adverse reactions

Herb/Ref.	Primary chemical constituents	Main effects/adverse reactions
Ginseng leaf, Piao et al[11], 2020	Ginsenoside	Reduces fasting blood glucose, regulates lipid metabolism, lowers inflammation and oxidative stress; adverse effects: Reproductive and developmental toxicity, CNS overexcitation, skin rashes
Usnea, Sepahvand et al[12], 2021	Usnic acid	Hepatocyte toxicity (the specific mechanism is yet to be confirmed)
Saposhnikovia, Yang et al[13], 2020	Chromones	Antipyretic, analgesic, anti-inflammatory, antioxidant, and antiplatelet effects
Schizonepeta, Zhao and Zhou[14], 2022	Volatile oils	Antiviral, anti-inflammatory, antitumor, antibacterial, immunomodulatory, and hemostatic effects
Angelica root, Bae et al[15], 2022	Volatile oils	Anti-inflammatory, analgesic, antitumor, antioxidant, antibacterial, and skin-whitening properties
Licorice, Shang et al[16], 2022	Dihydroflavones, glycyrrhizin, glycyrrhiza polysaccharides	Antitumor, anti-inflammatory, antiviral, and hepatoprotective effects
Sophora root, Huang et al[17], 2021	Alkaloids, flavonoids	Lipid accumulation, hepatotoxicity, inducing hepatic cytochrome P450 enzymes and accelerating drug metabolism may lead to the accumulation of metabolic intermediates and damage to liver cells. Some patients are allergic to flavonoid components, which triggers immune hepatitis, manifested as elevated ALT and jaundice. High concentrations of oxymatrine interfere with the mitochondrial respiratory chain, resulting in reduced ATP synthesis and accumulation of ROS
Zanthoxylum bungeanum, Bhambhani et al[18], 2021	Alkaloids, volatile oil	Hepatotoxicity, affects the blood supply of the liver. The metabolite epoxymelitticin has strong hepatotoxicity, causing liver cell necrosis and DNA alkylation. Long-term intake increases the risk of liver cancer. Oxidative stress: High-dose volatile oil depletes glutathione, inducing oxidative damage. Metabolic burden: Long-term and large intake aggravates the metabolic burden on the liver, especially for patients with alcoholic liver disease or hepatitis

CNS: Central nervous system; ALT: Alanine aminotransferase; ALP: Alkaline phosphatase; ROS: Reactive oxygen species.

Table 3 Viral immunity test

Item	Result
HAV	Negative
HBV	Negative
HCV-IgG	Negative
HEV	Negative
HIV	Negative
TP	Negative
EBV	Negative
TOX	Negative
CMV	Negative
HSV	Negative
HBsAg (IU/mL)	Negative
HBeAg (S/CO)	Negative
HBsAb (mIU/mL)	Negative
HBeAb (S/CO)	Negative
HBcAb (S/CO)	Negative
HBV-DNA (IU/mL)	0 IU/mL

HAV: Hepatitis A virus; HBV: Hepatitis B virus; HCV-IgG: Hepatitis C virus-immunoglobulin G; HEV: Hepatitis E virus; HIV: Human immunodeficiency virus; TP: Treponema pallidum; EBV: Epstein-Barr virus; TOX: Toxoplasma; CMV: Cytomegalovirus; HSV: Herpes simplex virus; HBsAg: Hepatitis B surface antigen; HBeAg: Hepatitis B e antigen; HBsAb: Hepatitis B surface antibody; S/CO: Signal/cut-off; HBeAb: Hepatitis B e antibody; HBcAb: Hepatitis B core antibody; HBV-DNA: Hepatitis B virus-deoxyribonucleic acid.