A 54-year-old woman is evaluated for abdominal discomfort. She has been feeling weak for the past 7 days. The patient is not eating well due to nausea and has noticed that her urine has become darker. She has a history of hypertension and generalized anxiety disorder. Her medications include amlodipine and chlorthalidone. For the past 4 months she has also been using ginseng as an energy booster and kava kava to control her anxiety. Two months ago, the patient started using Gingko biloba in an attempt to improve her memory. She states that she had been feeling better, less anxious, and more alert until last week. The patient does not use tobacco, alcohol, or illicit drugs. Examination shows mild jaundice. Heart sounds are normal and lung sounds are clear. The liver is palpable 2 cm below the costal margin and tender. Neurologic examination reveals no abnormalities. Her laboratory tests are as follows: Which of the following is the most likely cause of the patient's disease?

Question

A 54-year-old woman is evaluated for abdominal discomfort.  She has been feeling weak for the past 7 days.  The patient is not eating well due to nausea and has noticed that her urine has become darker.  She has a history of hypertension and generalized anxiety disorder.  Her medications include amlodipine and chlorthalidone.  For the past 4 months she has also been using ginseng as an energy booster and kava kava to control her anxiety.  Two months ago, the patient started using Gingko biloba in an attempt to improve her memory.  She states that she had been feeling better, less anxious, and more alert until last week.  The patient does not use tobacco, alcohol, or illicit drugs.  Examination shows mild jaundice.  Heart sounds are normal and lung sounds are clear.  The liver is palpable 2 cm below the costal margin and tender.  Neurologic examination reveals no abnormalities.  Her laboratory tests are as follows:  Which of the following is the most likely cause of the patient's disease?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c014_0310_8f63_d19a4843cb32_MD0005_00 This patient likely has drug-induced liver injury due to the use of kava kava, an herbal dietary supplement. More than a third of the population in the United States uses herbal supplements and approximately 20%-70% of drug-induced liver injury cases are caused by these agents. Many individuals do not inform their physician of herbal supplement use as they do not view them as medications and are concerned that their physicians may have negative views. Patients may also not be asked about supplements specifically. Kava kava (Piper methysticum) is an herbal supplement that has been used for anxiety, insomnia, and menopause. Hepatoxicity and liver failure is a potentially serious adverse effect that may occur several weeks to 2 years after intake. The mechanism is unclear, but the United States Food and Drug Administration issued a warning to the public concerning its use in 2002. (Choice A) The classic presentation of acute viral hepatitis is a period of fever, malaise, asthenia, and nausea, followed by jaundice. It is usually associated with marked elevations in serum aminotransferase levels (eg, >1000 U/L). This patient's mild-moderate aminotransferase elevations (<15 times the normal limit) in the setting of herbal supplement use make the diagnosis less likely. (Choice B) Thiazide diuretics (eg, chlorthalidone) can be associated with hypokalemia, hyponatremia, hyperuricemia, and elevation in serum glucose and cholesterol levels; however, hepatoxicity is extremely rare. (Choice C) Gingko biloba may be associated with an increased risk of bleeding due to possible anticoagulant and antiplatelet effects; however, it would not explain this patient's liver injury. (Choice D) The most common adverse effects of ginseng include headache, insomnia, and gastrointestinal symptoms. It may also be associated with vaginal bleeding and hypoglycemia. When used as monotherapy, it does not appear to cause hepatotoxicity. Educational objective: It is important to ask patients about the use of herbal dietary supplements as these agents can be associated with adverse effects. Kava kava is a supplement that has been used for anxiety and insomnia but may result in hepatoxicity and liver failure several weeks or more after intake. References: Kava hepatotoxicity--a clinical review. (http://www.ncbi.nlm.nih.gov/pubmed/20720265) Hepatotoxic botanicals - an evidence-based systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/24021288) Review article: herbal and dietary supplement hepatotoxicity. (http://www.ncbi.nlm.nih.gov/pubmed/23121117)

A 54-Year-Old Woman Is Evaluated for Abdominal Discomfort