A Unique Case of Acute Hepatitis Developing after Fo-Ti Root Ingestion

Purpose: The use of dietary and herbal supplements by adults in the United States increased from 23 million to over 38 million users between 1997 and 2002. Although herbal products are thought to be safe by many people, they may have biological activity that can lead to “therapeutic misadventures”. We describe one such case. A 26 year old woman from the Philippines presented with two days of non-bloody, non-bilious vomiting and abdominal pain that started after an alcoholic binge. She denied having any medical problems, prior heavy alcohol use, or any similar episodes in the past. She had been taking an over the counter (OTC) beauty supplement “RejuviCare™ - hair and nail formula” the contents of which included Fo-Ti root (Polygonum multiflorum) for the past three months. She denied any illicit drug use. On examination, the patient's vital signs were stable and she was afebrile. Abdominal examination was significant for mild right upper quadrant tenderness without any guarding or rigidity. Pertinent laboratory data included Aspartate aminotransferase/Alanine aminotransferase (AST/ALT) 3357/2887 U/L, Alkaline phosphatase 56 U/L, Gamma-glutamyl transferase 72 U/L, total bilirubin 1.3 mg/dl, conjugated bilirubin 0.5 mg/dl, albumin 4.5 g/dl. The complete blood count, serum chemistry, coagulation profile, viral hepatitis serologies, iron panel, ferritin, ceruloplasmin, alpha one antitrypsin, anti nuclear antibody, and tissue transglutaminase antibody were normal. Anti smooth muscle antibody and anti mitochondrial antibody were mildly elevated with titers of 1:40 and 1:20 respectively. Liver ultrasound was normal. A liver biopsy revealed scattered foci of lobular necroinflammation, aggregates of ceroid containing macrophages, no evidence of chronic liver injury, grade 2/4 inflammation, and stage 0/4 fibrosis. These findings were consistent with acute toxic liver injury. The herbal medication was discontinued and serial liver function tests showed gradual improvement and complete normalization after three weeks. Liver toxicity with the use of herbal medication containing Fo Ti root is rare in the reported literature. Fo Ti root has been thought to contain an alkaloid that may have rejuvenating effects on brain cells, nerves and endocrine glands. The side effects of this remedy are unknown and are considered safe for use by many people. There have been two other cases reporting a cholestatic hepatitis with the use of Fo Ti root. Our case is unique in that it is the first reported case with a hepatocellular hepatitis and normal bilirubin. This case points to the importance of a detailed history in assessing patients with acute hepatitis as patients often fail to mention the use of OTC medications.