Hepatitis-associated aplastic anemia from workout supplement: Rare but potentially fatal entity

Hepatitis-associated aplastic anemia (HAAA) is a rare clinical syndrome characterized by bone marrow failure 1-3 months after development of hepatitis. Untreated, hepatitis-associated aplastic anemia has poor outcome and the mainstay of treatment remains either bone marrow transplant or immunosuppressive therapy. A previously healthy 21-year-old man presented with a 1-week history of right upper quadrant pain and jaundice. Admission labs revealed mixed hyperbilirubinemia and elevated transaminases ranging in 2000s IU/dl. Extensive workup for etiologies of acute hepatitis including viruses, autoimmune, toxins etc. were negative. He admitted to taking "Dust V2," a workout supplement, for 4 months prior to the presentation. His liver function tests started to improve after conservative treatment. Two months after his discharge, he was found to have severe pancytopenia on routine labs. Bone marrow biopsy revealed hypocellular marrow consistent with aplastic anemia. Extensive workup for etiologies of aplastic anemia were negative. On literature review, none of the components of the supplement were found to cause aplastic anemia. A diagnosis of hepatitis-associated aplastic anemia was made as there was a lag time before development of anemia. His counts failed to improve despite treatment with filgrastim and he was referred for hematopoietic cell transplant.