Kava Herb-Induced Liver Injury as Verified by the Updated RUCAM

A temporal relationship between liver enzyme derangement and an herbal remedy warrants further assessment for herb-induced liver injury (HILI). Here, we describe the use of kava, a drink traditionally consumed in Pacific Island cultures, causing acute ALT and AST elevation as assessed by an updated RUCAM score of 7. The increasing use of kava in Western society should prompt clinicians to be more aware of this rare cause of HILI. A 46-year-old man was referred to the emergency department with a 3-week history of fatigue, right upper quadrant pain, and profound transaminitis. He commenced kava 10 g daily 5 weeks prior to aid sleep, which was ceased 2 weeks prior due to his biochemical derangement. Blood tests revealed an ALT of 1546 U/L and an AST of 920 U/L. An autoimmune screen, viral serology, and liver ultrasound showed no abnormalities. A liver biopsy revealed foci of hepatocellular necrosis with scattered ballooning degeneration and apoptotic bodies in the parenchyma, but normal underlying hepatic parenchyma without steatosis. Following cessation of kava, the liver enzymes improved without any other intervention. He was monitored as an outpatient and had no recurrence. The incidence of kava HILI may increase with its marketing; its exact mechanism is unknown. Ultimately, further research is needed to identify the pathogenesis of kava HILI. HILI is a significant cause of transaminitis, and clinicians should remain vigilant in patients presenting with nonspecific symptoms and a negative liver screen.