S5613 A Case Report: Drug-Induced Liver Injury from Prolonged Topical Application of Noni (Morinda citrifolia)

Introduction: Noni (Morinda citrifolia) is a plant-based supplement that has antioxidant, anti-inflammatory and immunomodulating effects. It can be found in many formulations including oral supplements, juice, topical ointments. There have been sparse case reports on the juice and oral supplementations of Noni associated with transaminitis. However, there have been no reported instances of transaminitis linked to the topical use of Noni. Case Description/Methods: We present a case of a 60-year-old man with a history of hypertension and hypothyroidism presented with jaundice, generalized pruritus, dark yellow urine, and acholic stools persisting for 5 days. Laboratory findings revealed elevated liver enzymes and a cholestatic pattern of injury. The patient had used a topical Morinda citrifolia-based analgesic cream for 8 months before discontinuing it 3 months prior to the onset of symptoms. Extensive diagnostic evaluation excluded viral, autoimmune, and metabolic causes of liver dysfunction, leading to a diagnosis of drug-induced liver injury secondary to the prolonged use of Noni products. Patient was closely monitored outpatient after discontinuation of topical Noni with normalization of the liver function tests within 6 months. Discussion: The elevation of liver enzymes secondary to the use of topical Noni is exceptionally rare in literature. Prior case reports showed the association through systemic means of absorption, but not through topical use. This case highlights the hepatotoxic potential of Morinda citrifolia, with topical application, and the importance of recognizing herbal products as potential contributors to liver injury. While the true mechanism of hepatotoxicity is not fully understood, one proposed mechanism could be anthraquinones' induced production of reactive oxygen species leading to the disruption of mitochondrial respiration, impairment energy production in hepatocytes that leads to cell apoptosis or necrosis. Further studies are needed to delineate the mechanism of absorption and toxicity for topical noni products.