S5504 Reishi Mushroom Toxicity in Chronic Liver Disease

Introduction: Ganoderma lingzhi (the Reishi mushroom) has become a popular supplement that boosts the immune system, with claimed antioxidant properties. However, there is limited data on its safety and potential liver toxicity. Case Description/Methods: A 51-year-old woman with a history of alcohol use disorder presented for abnormal liver enzymes. She had a recent hospitalization for acute liver injury requiring N-acetyl cysteine (NAC). She endorsed progressive fatigue and abdominal pain with labs showing abnormal liver enzymes with hepatocellular injury pattern and impaired liver synthetic function. An extensive serological work up for chronic and acute liver disease was negative for viral hepatitis, metabolic and genetic liver diseases. She received NAC and supportive care with initial improvement in aminotransferases. Her total bilirubin continued to increase during this admission. She underwent a liver biopsy showing bridging fibrosis, minimal interface change, variable macrovesicular steatosis, and zone III hepatocellular collapse suggestive of potential drug induced liver injury-autoimmune hepatitis. Two weeks after discharge, she returned with worsening abdominal pain, jaundice, with worsening cholestatic liver injury. Upon detailed review she endorsed long-term use of Lingzhi powder for a duration of 3 months. The last consumption was 2 months prior to the initial presentation. She also reported daily alcohol consumption. Medical therapy of prednisone taper, azathioprine, and ursodiol was initiated. The patient liver function test continued to improve over the course on azathioprine upon outpatient follow-up at 2 months after discharge. Discussion: Ganoderma lingzhi, commonly known as Reishi mushroom, has seen a surge in popularity as a natural health supplement, with U.S. sales reaching $3.6 million in 2019. The increase in Reishi mushroom consumption over the years is paralleled by a growing number of drug-induced liver injury cases (DILI), which now account for over 20% of all reported liver injury. This is the second documented case of Reishi mushroom related DILI in patients with underlying alcoholic liver disease. The incidence and risk factors for Ganoderma genus induced liver injury is limited and complicated by conflicting clinical data. Ganoderma lucidum—a different form—has shown hepatoprotective effects in animal studies, particularly through modulation of the TLR4/NF-kB/MyD88 signaling pathway. This case underscores the importance of herbal supplements in chronic liver disease.