S5536 The Mystery Is in the History: HDS-Induced Liver Injury

Introduction: With rising obesity rates and limited access to prescription weight loss drugs, more people are turning to over-the-counter herbal and dietary supplements (HDS) for weight loss. HDS-induced liver injury (HILI) from weight loss products poses a diagnostic challenge. HILI can mimic other hepatobiliary disorders, and patients are less likely to report their HDS use to providers without detailed medication use questioning. Case Description/Methods: A 39-year-old man with history of metabolic dysfunction-associated steatohepatitis presented with epigastric pain, jaundice, and subjective fevers. Labs showed alanine aminotransferase (ALT) 269, aspartate aminotransferase (AST) 216, alkaline phosphatase (ALP) 383, bilirubin 8.5 (direct 5.5). He mentioned using an HDS to increase his metabolism, because insurance denied prescription weight loss medications. Computed tomography abdomen showed reactive lymphadenopathy in the upper abdomen. Antibiotics were started for suspected biliary infection. Serologies for toxic, viral, fungal, autoimmune and hereditary liver disease were negative. Magnetic resonance cholangiopancreatography showed diffuse hepatic steatosis. With persistent epigastric pain and worsening cholestasis, choledocholithiasis was suspected. Subsequent endoscopic retrograde cholangiopancreatography was normal; biliary stent was placed. Liver tests did not improve, so liver biopsy was obtained, showing moderate steatohepatitis, significant bile ductular proliferation, scattered mild plasmocytic infiltrate, and microgranulomas. Autoimmune hepatitis with AMA-negative primary biliary cholangitis was the leading diagnosis. Ursodiol and steroids were started. The patient was discharged home after 10 days with AST 65, ALT 98, ALP 487, bilirubin 2.8 (direct 1.3) and continued treatment. The patient followed up in clinic and revealed that he used 3 bottles of weight loss HDS for 3 months before liver injury onset. These products contained green tea leaf extract, turmeric root powder, turmeric root extract, black pepper fruit extract. With this new information, the liver injury was deemed likely due to HILI. Prednisone and ursodiol were discontinued. All liver tests normalized and remained normal 10 weeks after liver injury onset. Discussion: This case shows how HILI is a major diagnostic challenge and can mimic other hepatobiliary conditions. Our patient took products containing well-documented synergistic hepatotoxins (green tea leaf extract, and turmeric with black pepper) which increase turmeric bioavailability and potential toxicity. Clinicians should have a high index of suspicion for HILI in cases of unexplained liver injury. A detailed medication use history is needed for early diagnosis and to avoid unnecessary testing.