Severe liver injury due to Epsom salt naturopathy.

Philips CA, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-221718 Description A 38-year-old non-alcoholic, non-diabetic man with gallstone disease was prescribed three tablespoons of Epsom salt (magnesium sulfate crystals) with lukewarm water for 15 days for ‘stone dissolution’ by a naturopathy practitioner. He developed loss of appetite and darkening of urine from the 12th day on treatment and jaundice from the second day after treatment completion. The patient denied fevers, skin rash, joint pains, myalgia, abdominal pain, abdominal distension and cholestatic symptoms. Examination revealed a deeply icteric patient oriented to time, place and person without organomegaly or stigmata of chronic liver disease. Blood investigations revealed platelet count 190 (normal 150–450 x 10/L), total bilirubin 12.8 (39.3 mmol/L) (normal 0.3–1.0 mg/ dL or 5.0–17.0 mmol/L), direct bilirubin 6.9 (21.7 mmol/L) (0.0–0.2 mg/dL or 0.0–3.4 mmol/L), aspartate aminotransferase 508 (<37 U/L), alanine aminotransferase 228 (<41 U/L), γ-glutamyltransferase 298 (5–61 U/L), alkaline phosphatase 178 (35–129 U/L), albumin 4.2 (3.5–5.0 g/dL) and international normalised ratio 1.1 (0.9–1.2). R ratio was 3.84 and Roussel Uclaf Causality Assessment Method score was 8 (probable adverse drug reaction). Serum magnesium was 3.1 (1.7–2.4 mg/dL). Tests for viral hepatitis A, E, B, C, cytomegalovirus, Epstein-Barr and herpes simplex viruses and those for autoimmune hepatitis and IgG4 disease were unremarkable. There was no evidence of underlying sepsis and other organ failures. Contrast enhanced CT of upper abdomen revealed only hepatomegaly with mild periportal oedema. Percutaneous liver biopsy revealed submassive necrosis with dense portal-based fibrosis, mixed portal inflammation, extensive perivenular canalicular and hepatocellular cholestasis with macrovesicular steatosis and perisinusoidal fibrosis (suggestive of steatohepatitis) without evidence of granulomas, inclusion bodies or vascular changes suggestive of acute drug-induced liver injury (figure 1). Polarising Severe liver injury due to Epsom salt naturopathy Cyriac Abby Philips, Rajaguru Paramaguru, Pushpa Mahadevan, Philip Augustine Images in...