TITLE : Expecting the Unexpected : Black Cohosh - induced Hepatotoxicity Leading to Early Cirrhosis CONTACT (

BODY: Purpose: There have been many reports of toxicity associated with use of dietary supplements; some of these cases have lead to fatal outcomes. We report a rare case of fulminant liver failure assumed to be from ingestion of SlimQuickTM (Wellnx Life Sciences, Wilmington, DE) weight loss supplement containing green tea extract (GTE). Case Report: A 52-year-old woman presented to the Emergency Department with one week of vomiting and progressive jaundice. On further questioning, the patient reported two days of ingesting the weight loss supplement SlimQuickTM while fasting 3 weeks before presentation. Past medical, surgical and family histories were unremarkable. Physical examination showed normal mental status, icteric sclera, mild abdominal distension and lower extremity edema. Initial workup showed total bilirubin of 16.5 mg/dL, AST 1507 IU/L, ALT 945 IU/L, alkaline phosphatase 210 IU/L and INR 2.82. CT abdomen revealed nodular liver with small amount of ascites. Serological tests for viral hepatitis, autoimmune hepatitis, Wilson disease, and primary biliary cirrhosis were negative. Liver biopsy was consistent with confluent hepatic necrosis with collapse. In the unlikely possibility that there was an autoimmune etiology to her acute liver injury, Prednisone 60mg was initiated but discontinued two days later due to worsening liver function. A day later, the patient’s mental status began to deteriorate. The patient was expeditiously evaluated and listed for liver transplant. She underwent liver transplantation two days later. The patient was discharged home postoperative day eight. Discussion: To our knowledge, this is the first reported case of fulminant liver due to ingestion of SlimQuickTM. The major ingredient in SlimQuickTM is GTE. GTE is a common ingredient in several dietary supplements, some of which have been withdrawn from the market due to safety concerns. An example of this is Exolise® (Arkopharma, France), a weight loss supplement containing GTE that was withdrawn from the market due to 13 cases of liver injury. Since 1966, 34 case reports of liver toxicity with GTE were identified by the United States Pharmacopeia. The majority of cases present with an acute hepatocellular injury pattern and most recover with cessation of use. An idiosyncratic or an immune-allergic mechanism appears to be the likely mechanism of injury. Animal studies with high doses of GTE have described dose dependent hepatotoxicity resulting in severe morbidity and mortality. This demonstrates the importance obtaining herbal and dietary supplement history in previously healthy subjects who develop liver injury. Methods: N/A Results: N/A Conclusion: N/A (no table selected) (No Image Selected) Video Submission Confirmation: No Video Upload: Abstract Author: Investigator Commercial Products or Services: Yes Designed Study: Investigator FDA Approval: No Financial Relationships: No Initiated Research: Investigator Investigator Contribution: No Performed Analysis: Investigator Secondary Analyses: Not Applicable Study Results: Yes Submit: Supported by Industry Grant: No CONTROL ID: 1737911 TITLE: Expecting the Unexpected: Black Cohosh-induced Hepatotoxicity Leading to Early Cirrhosis CONTACT (NAME ONLY): Muhammad Khan ABSTRACT STATUS: Sessioned AUTHORS/INSTITUTIONS: K. Chaudrey, M.S. Khan, J. Fazili, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, UNITED STATES| ABSTRACT BODY: Purpose: Herbal supplements are commonly used by patients for various problems. It is a well-known fact that most patients do not tell their physicians regarding use of herbal supplements unless specifically asked. As a result, sometimes important points from drug side effects are missed in history taking. In this context, we present a rare case of Black Cohosh-induced hepatotoxicity leading to early cirrhosis.BODY: Purpose: Herbal supplements are commonly used by patients for various problems. It is a well-known fact that most patients do not tell their physicians regarding use of herbal supplements unless specifically asked. As a result, sometimes important points from drug side effects are missed in history taking. In this context, we present a rare case of Black Cohosh-induced hepatotoxicity leading to early cirrhosis. Case Description: A 44-year-old female with no PMH presented with complaints of painless jaundice for one month. She went to her PCP, where initial work-up revealed that she had elevated LFTs. She was noted to have normal LFTs on her prior lab works. Work-up for viral and autoimmune hepatitis was negative. She was given a trial of steroids on outpatient basis without much improvement. She was referred to inpatient evaluation because of gradual progression of her symptoms. She denied history of alcohol intake, IV drug use, unprotected sex, recent travel outside the U.S., NSAID ingestion or blood transfusions. She reported no abdominal pain, fever, chills, nausea vomiting or diarrhea. She did report generalized itching, arthralgia and fatigue. She interestingly reported that she started taking Black Cohosh for alleviation of her menstrual symptoms about one month back. Her exam was remarkable for marked scleral icterus and jaundiced skin. On admission, her LFT showed TBil =20, AST=420, ALT=215, AlkPhos=201, Platelets=135, INR 1.2 and Albumin=2.4. Ultrasound abdomen showed nodular contour of liver consistent with cirrhosis. Further work-up ruled out Wilson’s disease, Hemochromatosis, AMA negative PBC and autoimmune hepatitis. Liver biopsy was performed, which showed histologic pattern consistent with cholestasis, hepatocellular injury and early cirrhosis. Given patient’s history of Black Cohosh use and the timing of her abnormal liver chemistries, it was clinically evident the culprit agent was Black Cohosh. Her symptoms improved, and her LFT’s normalized after she stopped taking Black Cohosh. Discussion: Black Cohosh, also named as Cimicifuga racemosa, is among commonly used herbal supplements in the United States for menstrual symptoms. There are few case reports available in literature that attribute Black Cohosh to liver injury. In most instances, the liver injury ranges from jaundice, mild transaminasemia to rare cases of fulminant hepatic failure. Our case is unique, since it represents development of accelerated cirrhosis in our patient for a relatively short period of time. This case is to bring awareness amongst clinicians about this potentially unexpected outcome in the backdrop of much-expected drug induced hepatitis. Methods: N/A Results: N/A Conclusion: N/A (no table selected) (No Image Selected) Video Submission Confirmation: No Video Upload: Abstract Author: Investigator Commercial Products or Services: No Designed Study: Investigator FDA Approval: No Financial Relationships: Not Applicable Initiated Research: Investigator Investigator Contribution: No Performed Analysis: Investigator Secondary Analyses: Not Applicable