S5400 Unmasking Herbal Hepatotoxicity: Severe Drug-Induced Liver Injury with Autoimmune Features Following Black Cohosh Exposure

Introduction: Drug-induced liver injury (DILI) is a leading cause of abnormal liver function tests and acute liver failure in the United States. DILI can result from prescription medications, over-the-counter drugs, or herbal supplements, and often mimics other liver diseases, making diagnosis challenging. Clinical presentations range from asymptomatic enzyme elevations to jaundice, pruritus, fatigue, and abdominal pain. Laboratory findings typically reveal elevated aminotransferases and bilirubin; severe cases may show impaired coagulation. DILI is classified as intrinsic or idiosyncratic. Risk factors include older age, pre-existing liver disease, alcohol use, genetics, and polypharmacy. Management centers on discontinuing the offending agent and supportive care, with specialist referral for severe presentations. A thorough medication and supplement history is essential for diagnosis. Case Description/Methods: A 58-year-old woman with Hashimoto thyroiditis and asthma presented with severe transaminitis after returning from Egypt, where she had cataract surgery. She developed jaundice postoperatively and was hospitalized abroad, with bilirubin peaking at 32 mg/dL and aspartate aminotransferase/alanine aminotransferase >2500 IU/L. She denied viral symptoms, new medications, acetaminophen, antibiotics, supplements, or alcohol use. On arrival, her liver function tests (LFTs) remained elevated. Workup for viral, autoimmune, and metabolic causes was negative; imaging showed hepatic steatosis. Coagulation studies revealed signs of liver regeneration. Transjugular liver biopsy showed severe hepatitis with plasma cell clusters and granulomas, suggestive of DILI with atypical autoimmune features. The patient later recalled possible use of herbal remedies, including black cohosh. She was managed with continuous N-Acetyl Cysteine (NAC), ursodiol, steroids, and vitamin K for coagulopathy. Her LFTs improved, and she was discharged on a steroid taper and supportive care. Discussion: This case highlights the importance of considering herbal supplement–induced DILI in patients with acute hepatitis of unclear etiology. Black cohosh, though rarely, has been associated with severe hepatotoxicity. Management relies on prompt withdrawal of the suspected agent, supportive care, and, in cases with autoimmune features, corticosteroids. NAC may benefit non-acetaminophen acute liver failure. Early liver biopsy and a detailed history are essential for diagnosis and guiding therapy. Vigilance regarding herbal and alternative medicine use is critical for clinicians evaluating acute liver injury.