S5673 Not All That’s Herbal Is Healthy: A Case of Drug-Induced Liver Injury With Autoimmune Features From Turkesterone

Introduction: Drug-induced liver injury (DILI) is a leading cause of acute liver injury in the United States, with an annual incidence of 15 to 20 per 100,000. Serologic and histologic features of autoimmune hepatitis (AIH) may present with DILI and cause diagnostic uncertainty. Here, we report a case of a patient with Turkesterone-related DILI with autoimmune features. Case Description/Methods: A 39-year-old man with a history of subfulminant liver failure post liver transplantation in 2011 presented to the emergency department with a 3-week history of generalized weakness, poor appetite, nausea, and dark urine. Laboratory testing revealed elevated liver enzymes compared to 10 months prior, which were within normal limits. Liver ultrasound showed patent portal and hepatic veins, and a computed tomography (CT) scan of the abdomen and pelvis revealed no pathology. Tests for viral hepatitis, cytomegalovirus (CMV), and antinuclear antibodies (ANA) were negative. Serology revealed elevated IgG levels at 1800 mg/dL, and positive anti-smooth muscle antibodies (ASMA) at 38 U. His liver-kidney microsomal antibodies (LKM) were negative. He later revealed that he has been taking a supplement of turkesterone for the past 2 months. Liver biopsy demonstrated lymphoplasmacytic portal inflammation with interface activity consistent with autoimmune hepatitis (AIH) or DILI. The patient was treated with 500 mg of methylprednisolone, with rapid improvement of his symptoms. He was discharged on a prednisone taper with recovery of his liver enzymes at 2-month follow-up. Discussion: Turkesterone is part of the ecdysteroid family, a group of plant hormones studied for their anabolic effects. Data on its safety is limited. Our patient was taking approximately 160 mg of turkesterone, far exceeding the doses investigated in available studies. The temporal relationship of the patient’s supplement intake, onset of liver injury, histologic findings on biopsy, and subsequent improvement with glucocorticoid therapy strongly suggests turkesterone-related DILI with autoimmune features. While drugs like nitrofurantoin, minocycline, hydralazine, and methyldopa are known to cause DILI with autoimmune features, cases implicating herbal supplements are rare. This case highlights the importance of a thorough review of the use of herbal and dietary supplements with patients.