Ashwagandha-Induced Herb-Induced Liver Injury Assessed With the Updated 2016 RUCAM

Ashwagandha-induced herb-induced liver injury (HILI) has increasingly been reported; however, many published cases show methodological variability in causality assessment and limited clinicopathological correlation. We present a case of ashwagandha-associated liver injury with systematic causality evaluation using the updated 2016 Roussel Uclaf Causality Assessment Method (RUCAM) and comprehensive clinicopathological correlation. A previously healthy 27-year-old woman developed jaundice and generalized pruritus after consuming ashwagandha for three days. Infectious, autoimmune, and metabolic etiologies were excluded. Abdominal magnetic resonance imaging showed no structural abnormalities, while liver biopsy demonstrated a classic cholestatic pattern without fibrosis. Causality assessment using the updated 2016 RUCAM yielded a score of 7 points, consistent with probable HILI. The patient received symptomatic management, corticosteroids, and azathioprine, with progressive clinical and biochemical improvement. This case highlights the value of a systematic causality approach using updated RUCAM criteria together with complete clinicopathological correlation to strengthen diagnostic confidence in suspected HILI associated with herbal supplements.