S5917 Case Report: Probable Drug-Induced Liver Injury Due to Heart-Leaved Moonseed

Introduction: Heart-leaved Moonseed (Tinospora cordifolia), also known as Guduchi, is widely used in traditional medicine as an immune booster. Despite its popularity, recent reports suggest a potential association with drug-induced liver injury (DILI), although cases remain rare. We present a case of acute hepatitis with a cholestatic pattern in an elderly male, likely related to long-term use of Heart-leaved Moonseed. Case Description/Methods: A 77-year-old Asian male from Thailand with a history of type 2 diabetes, hypertension, and hyperlipidemia presented with one week of dark urine. He denied abdominal pain, fever, or alcohol use and had been in his usual state of health prior to symptom onset. Notably, he had been taking T. cordifolia daily for 5–6 months as an immune supplement, which he discontinued a few weeks prior. Initial labs showed a hepatocellular-predominant injury pattern with marked transaminitis (aspartate aminotransferase 978 U/L, alanine aminotransferase 432 U/L), elevated total bilirubin (9.5 mg/dL; direct 7.3 mg/dL), and mildly elevated international normalized ratio (1.2). Acetaminophen and urine drug screen were negative. Imaging revealed periportal edema and cholelithiasis without biliary obstruction or abnormal liver morphology. Extensive workup for viral, metabolic, and genetic liver diseases was negative. Autoimmune testing revealed a positive ANA (1:640), elevated ASMA (123 U), and elevated IgG (2072 mg/dL), raising suspicion for autoimmune or drug-induced autoimmune hepatitis. The patient received a 72-hour N-acetylcysteine protocol without clinical improvement. Because liver tests remained abnormal and autoimmune markers were positive, corticosteroid therapy was started: intravenous Solu-Medrol followed by an oral prednisone taper. Liver enzymes and bilirubin subsequently improved. He is now being monitored in the outpatient setting. Discussion: T. cordifolia is a popular traditional remedy, especially in South Asian countries. Although reported cases of liver injury are rare, T. cordifolia has the potential to cause acute hepatitis, often presenting with features resembling autoimmune hepatitis. Thus, careful monitoring for adverse effects is warranted in patients using T. cordifolia.