[Lethal course: When plants affect the liver]

Area of Science:

• Hepatology
• Toxicology
• Internal Medicine

Background:

• A 55-year-old presented with jaundice and decreased performance after 4 months of Chinese herb use.
• Clinical signs included jaundice, right upper quadrant tenderness, and grade I hepatic encephalopathy (HE).
• Initial lab work showed coagulopathy, elevated transaminases, and cholestasis with minimal hyperammonemia.

Purpose of the Study:

• To report a case of acute liver failure (ALF) attributed to Chinese herbal medicine.
• To emphasize the importance of timely diagnosis and management of ALF.
• To highlight the critical need for prompt referral for liver transplantation.

Main Methods:

• Case report analysis of a patient with suspected drug-induced liver injury.
• Clinical examination, laboratory testing (liver function tests, coagulation profile, ammonia levels), and abdominal sonography.
• Review of patient history regarding herbal supplement intake and progression of symptoms.

Main Results:

• Diagnosis of acute liver failure (ALF) was established based on clinical presentation, laboratory findings, and temporal association with Chinese herb consumption.
• Imaging excluded underlying liver fibrosis, cirrhosis, or perfusion disorders.
• Delayed referral for liver transplantation due to patient's ambivalence preceded graft failure and a fatal outcome post-re-transplantation.

Conclusions:

• Chinese herbal medicine can induce acute liver failure (ALF) even in previously healthy individuals.
• Timely recognition of ALF (defined by HE and INR ≥ 2) and prompt referral to a transplant center are critical for improving patient outcomes.
• Complications such as abdominal compartment syndrome and thromboembolism can occur during post-transplant management, underscoring the complexity of ALF cases.