A 36-year-old female with no significant medical history presented with a 3-day history of low-grade fever, nausea, vomiting, and abdominal pain. She reported that she had been following a 500 Kcal diet and was taking GC for four weeks to lose weight. She also complained of fatigue, anorexia, and jaundice. The patient denied any history of recent blood transfusion, illicit drug use, or family history of liver disease. She denied alcohol consumption and was in a monogamous heterosexual relationship.\nOn physical examination, she had scleral icterus, cutaneous jaundice, and tender hepatomegaly measuring 2 cm below the costal margin. Abnormal laboratory results included white blood cell count of 2.73 × 103 cells/μL (4–11) and platelet count of 78 × 103 cells/μL (150–400), aspartate aminotransferase (AST) of 5340 U/L (15–41), alanine aminotransferase (ALT) of 5615 U/L (7–52), alkaline phosphatase of 104 U/L (32–91), total bilirubin of 7.4 mg/dl (0.3–1.0), and direct bilirubin of 4.9 mg/dl (0.0–0.4). Serologies for hepatitis A, hepatitis B, hepatitis C, autoimmune markers (anti-nuclear antibody, anti-smooth muscle antibodies, anti-mitochondrial antibody, and anti-liver kidney microsomal 1 antibody), human immunodeficiency virus, rapid plasma reagin test, cytomegalovirus, Epstein-Barr virus, Herpes Simplex virus, and Parvovirus were negative. Serum ceruloplasmin, alpha-fetoprotein, and alpha-1 antitrypsin levels were normal. Abdominal Doppler ultrasound showed mild echotexture coarsening in the liver and small ascites.\nConsidering her recent exposure to herbal medications, we suspected drug induced liver injury and used updated RUCAM (Roussel Uclaf Causality Assessment Method) scale to calculate its probability. Patient's RUCAM score came out to be 8 points, which is consistent with probable drug induced liver injury []. GC was discontinued and conservative management was initiated. Significant clinical improvement and the downward trend of liver function tests obviated the need for liver biopsy. The patient was discharged on hospital day 6. At follow-up visit two weeks later, her liver function tests had returned to normal ().
A 22-year-old obese female presented to the emergency department with complaints of chest pain, progressive fatigue, palpitations and shortness of breath for two days. She also noticed tremors in her hands. She denied any abdominal pain, nausea, vomiting, fever, chills or rash. She reported taking a herbal supplement for weight loss, named Proclinical Hydroxycut, two capsules daily for about three months. She denied alcohol use, recent travel, other medications/supplements, family history of autoimmune diseases.\nOn admission, vitals were significant for tachycardia with heart rate 113 beats per minute and oxygen saturation was 84% on room air. Physical examination was remarkable for obesity with body mass index (BMI) 41, mild asterixis bilaterally. No encephalopathy, scleral icterus or hepatosplenomegaly was found. Laboratory analysis showed leukocytosis with white blood cell count of 24 x 103/ul (4.4-10.5 103/ul), severe transaminitis with alanine aminotransferase (ALT) 2399 U/L (4-51 U/L), aspartate aminotransferase (AST) 4040 U/L (5-46 U/L),alkaline phosphatase level 72 U/L (40-129 U/L), total bilirubin 0.6 mg/dl (0.1-1.5 mg/dl), International Normalized Ratio (INR) 1.4 (0.8-1.2).\nInvestigations for other etiologies of acute liver injury including hepatitis panel, Tylenol level, antinuclear antibody, anti-smooth muscle antibody, anti-mitochondrial antibody, ceruloplasmin level, ferritin level, and serologies for Ebstein-Bar virus (EBV), herpes simplex virus (HSV) and cytomegalovirus (CMV) were unremarkable. Abdomen Ultrasound showed hepatomegaly and doppler studies of the liver were unremarkable (Figure ). Computed tomography (CT) scan of the chest showed developmental abnormalities like scoliosis and lung hypoplasia (Figure ).\nShe was diagnosed with acute drug-induced liver injury likely due to Hydroxycut and treated with N-acetylcysteine. Transaminases trended down during the course of hospitalization after Hydroxycut was stopped and levels were ALT 189 and AST 61 on day 8 (Figure ). She was discharged in stable condition to follow up outpatient with hepatology.