S4122 Hepatotoxicity and Systemic Symptoms Following Use of TikTok-Promoted Herbal Supplements: A Case Report

Introduction: Social media has been widely used for health-related purposes; however, the ease of access to health-related content on social media has aided in the promotion of unregulated supplements, such as ashwagandha. A concern is the promotion of herbal ingredients like ashwagandha, which are a growing cause of liver injury in the United States due to minimal regulatory oversight, frequent issues of contamination, and inaccurate labeling. Case Description: A 55-year-old man with hypertension, a former smoker, and alcohol use disorder presented with progressive dyspnea, near-syncopal episodes, and gastrointestinal symptoms, with unintentional weight loss of about 30 lb over 1 month. His symptoms began with nausea and dizziness and progressed to severe fatigue, lightheadedness, diarrhea, poor oral intake, and vomiting. The patient had been using TikTok-promoted supplements, sold as nitric oxide boosters and liver cleanse pills, with the main ingredient being ashwagandha. He discontinued the supplements a week before the presentation due to worsening symptoms. At admission, liver enzymes were elevated (ALT 758 U/L, AST 718 U/L, ALP 585 U/L, total bilirubin 2.3 mg/dL), which improved (ALT 325 U/L, AST 325 U/L, ALP 445 U/L, total bilirubin 1.9 mg/dL) throughout his hospitalization with stopping the supplements. Labs showed hyponatremia (Na 123 mmol/L), hypoalbuminemia (2.4 g/dL), thrombocytopenia (72,000/uL), and elevated INR (2.1), ferritin (4,699 ng/mL), triglycerides (390 mg/dL), and LDL (324 mg/dL). Imaging revealed hepatic steatosis, hepatomegaly, periportal edema, trace ascites, and no biliary obstruction. Supportive care and discontinuing supplements led to improvement, and the patient was discharged with a follow-up appointment in hepatology. Discussion: Ashwagandha (Withania somnifera), an Ayurvedic herb, has been associated with cholestatic or mixed-pattern hepatic injury, typically presenting with a latency of weeks to months after initiation. While the exact mechanisms remain unclear, proposed pathways include immune-mediated hepatotoxicity, formation of reactive metabolites, and mitochondrial dysfunction. In this case, non-standardized formulations and misinformation propagated through social media further amplify the unregulated use, contamination, and possible drug interactions. These findings stress the need for increased awareness and patient education to reduce the risk of herb-induced liver injury.