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.
A 27-year-old man with no significant past medical history presented as a referral from a community hospital for evaluation of hepatitis, initially diagnosed as choledocholithiasis. The patient complained of fever, chills, and abdominal pain (achy in the Right Upper Quadrant and epigastrium) for the past 2 weeks, nausea, and vomiting of clear liquids without blood for a 1 week, and jaundice for 2 days. Records from referring facility indicated that patient had MRCP-Magnetic Resonant Cholangio Pancreatography that demonstrated cholelithiasis, but it did not show any signs of cholecystitis. An abdominal ultrasound revealed sludge and gallstones in the gallbladder.\nFurther questioning revealed that patient had been studying to be a physical trainer at a local college. He exercised vigorously at least 3 times/week. Patient stated that he was “prescribed” a set of supplements (Hydroxycut, Black powder, mitotropin, xenadrine, arson, and L-glutamine powder 23) by his local nutrition center.\nAfter admission in the hospital, hepatology consult was called. When patient was admitted, liver enzymes panel showed: AST-Aspartate Aminotransferase: 3800 U/L, ALT-Alanine aminotransferase: 5100 U/L, total bilirubin: 14.7 mg/dl, direct bilirubin: 10.0 mg/dl and alkaline phosphatase: 99 mg/dl, all correlated with the degree of jaundice seen. Additional tests included a urine toxicology screen, immunological studies for liver (anti-nuclear antibodies, anti-smooth muscle antibodies, and anti A liver/kidney microsomal antibodies), serum acetaminophen level, serum ceruloplasmin level, and genetic tests for hemochromatosis; all of them were negative. Liver biopsy showed signs of acute liver failure.\nHematoxylin and eosin stain of the liver biopsy specimen is shown in Figures and . shows extensive patchy areas of necrosis as in acute fulminant hepatitis with sparing of biliary tract. shows lymphocytic infiltration of the portal tracts and lobular parenchyma.\nPatient was asymptomatic during the hospital stay and was planned to discharge with trending down of liver enzymes by discontinuation of Hydroxycut and conservative management. The patient was advised to follow-up with Hepatology. On follow-up visit after 2 weeks of discharge, Labs: AST: 669 U/L, ALT: 1965 U/L, Total Bilirubin: 4.5 mg/dl, Alkaline phosphatase: 128 mg/dl, PT: 1.1.