LETTERS TO THE EDITOR

 

Hepatic veno-occlusive disease induced by Chinese medicinal herbs

Enfermedad venooclusiva hepática inducida por hierbas medicinales chinas

 

 

---

Key words: Pyrrolizidine alkaloids. Medicinal herbs. Hepatic veno-occlusive disease.

Palabras clave: Alcaloides pirrolizidínicos. Hierbas medicinales. Enfermedad venooclusiva hepática.

---

 

Dear Editor,

The potential hepatotoxic effects of medicinal herbs is well known and these products are frequently used without an adequate control by the health authorities. We report a case of toxic hepatic veno-occlusive disease (HVOD) which was presumably associated with the use of these herbal remedies. In Asia, pyrrolizidine alkaloids found in herbal medicines are a common cause of HVOD (1,2).

 

Case Report

A 62-year-old Asian man was admitted to hospital due to hepatomegaly and jaundice (bilirubin, 23.6 mg/dl) with SGPT/SGOT at 1,301/506 IU/l and GGT at 527 IU/l. Vascular, obstructive, infectious and autoimmune conditions were ruled out. The liver biopsy was consistent with HVOD (Fig. 1). The patient reported the habitual use (until admission) of over-the-counter, unlabeled "laxative" capsules that he had purchased in China. An analysis performed at the Medicament Inspection and Control Department revealed that the capsules contained proline, anthraquinones and other unidentifiable compounds. He was discharged with no symptoms and only persistent mild cholestasis (GGT, 170 IU/l; Bb, 1.9 mg/dl).

 

 

Discussion

Preparations containing Chinese medicinal herbs that are frequently obtained for the management of minor symptoms usually have a mixed, nonspecific formulation that lack precise information with regard to content. Given their widespread use, the highly variable hepatotoxicity induced by these products (3) is rather uncommon (4).

Selected alkaloids produce a toxic destruction of sinusoidal endothelial cells which results in the obstruction of terminal venules (5). Diagnosing the toxic origin of HVOD requires histological confirmation, the exclusion of other causes and a clear temporal relationship. In mild/moderate cases, exposure discontinuation usually leads to a favorable outcome but high mortality rates have been reported on occasions (3). Language and culture barriers contribute to an even more challenging diagnosis.

 

Acknowledgements

We are grateful to doctors Miren García-Cortés and Jaime Torelló-Iserte for their expert advice.

 

María de los Ángeles Mejías-Manzano¹, Álvaro Giráldez-Gallego¹ and María Serrano-Jiménez^2
1Digestive Tract Management Unit. Hospital Universitario Virgen del Rocío. Seville, Spain.
²Pathology Department. Hospital Universitario Virgen del Rocío. Seville, Spain

 

References

1. Wang X, Qi X, Guo X. Tusanqi-related sinusoidal obstruction syndrome in China: A systematic review of the literatures. Medicine (Baltimore) 2015;94:942. DOI: 10.1097/MD.0000000000000942.         [ Links ]

2. Kan X, Ye J, Rong X, et al. Diagnostic performance of contrast-enhanced CT in pyrrolizidine alkaloids-induced hepatic sinusoidal obstructive syndrome. Sci Rep 2016;6:37998. DOI: 10.1038/srep37998.         [ Links ]

3. García-Cortés M, Robles-Díaz M, Ortega-Alonso A, et al. Hepatotoxicity by dietary supplements: A tabular listing and clinical characteristics. Int J Mol Sci 2016;17:537. DOI: 10.3390/ijms17040537.         [ Links ]

4. Navarro, VJ, Lucena MI. Hepatotoxicity induced by herbal and dietary supplements. Semin Liver Dis 2014;34:172-93. DOI: 10.1055/s-0034-1375958.         [ Links ]

5. Fan CQ, Crawford JM. Sinusoidal obstruction syndrome (hepatic veno-occlusive disease). J Clin Exp Hepatol 2014;4:332-46. DOI: 10.1016/j.jceh.2014.10.002.         [ Links ]