Case Report
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Nov 8, 2017; 9(31): 1205-1209
Published online Nov 8, 2017. doi: 10.4254/wjh.v9.i31.1205
Ayurvedic drug induced liver injury
Kunal K Dalal, Thomas Holdbrook, Steven R Peikin
Kunal K Dalal, Department of Medicine, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ 08103, United States
Thomas Holdbrook, Department of Pathology, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ 08103, United States
Steven R Peikin, Division of Gastroenterology and Liver Disease, Cooper Medical School of Rowan University, Cooper University Hospital, Camden, NJ 08103, United States
Author contributions: All authors took care of the patient medically; Dalal KK analyzed and drafted the report; Holdbrook T and Peikin SR made critical appraisals of the report.
Institutional review board statement: Cooper Health System Institutional Review Board does not require IRB review for Case Reports less than 5 patients.
Informed consent statement: Informed consent was acquired from the patient.
Conflict-of-interest statement: None of the authors have any financial disclosures or conflicts of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Kunal K Dalal, MD, Department of Medicine, Cooper Medical School of Rowan University, Cooper University Hospital, 1 Cooper Plaza, Camden, NJ 08103, United States.
Telephone: +1-856-3422000 Fax: +1-844-5116895
Received: May 3, 2017
Peer-review started: May 4, 2017
First decision: June 15, 2017
Revised: June 28, 2017
Accepted: August 3, 2017
Article in press: August 3, 2017
Published online: November 8, 2017
Case characteristics

A 44-year-old female had symptoms of painless jaundice, poor appetite, pale stools, and dark urine.

Clinical diagnosis

Patient with history of painless cholelithiasis and 6 mo use of herbal medication had worsening jaundice, scleral icterus.

Differential diagnosis

The differential diagnosis includes viral hepatitis, acetaminophen overdose, autoimmune hepatitis, ischemic hepatopathy, Wilson’s disease, acute Budd-Chiari syndrome, obstructive hyperbilirubinemia secondary to cholelithiasis, and the diagnosis of exclusion of drug induced liver injury.

Laboratory diagnosis

Laboratory findings included glutamic-oxalacetic transaminase 1092 U/L, alanine aminotransferase 1185 U/L, total bilirubin 9.0 mg/dL, direct bilirubin 6.2, negative hepatitis serologies, negative autoimmune serologies and negative HFE gene mutation.

Imaging diagnosis

Multiple imaging modalities were used, including right upper quadrant ultrasound demonstrating a gallbladder neck calculus, a HIDA scan demonstrating hepatic dysfunction with uptake in the gallbladder, and an magnetic resonance cholangiopancreatography confirming a gallbladder calculus, no choledocholelithiasis, and a unique heterogeneous T2 liver enhancement with no signs of hepatic steatosis.

Pathological diagnosis

Liver biopsy demonstrated grade 3 bridging fibrosis, ceroid-laden Kupffer cells, and eosinophils, which was all suggestive of drug hypersensitivity reaction with resolving hepatitis.


After diagnosis of this condition, the major treatment was stopping the offending medication and monitoring with serial LFTs until normalization.

Related reports

There have been case reports of herbal medication causing drug induced liver injury, but this case is unique because it represents the first documented case report of commonly used ayurvedic medications including Punarnava mandur and Kanchnar guggulu that was confirmed with biopsy and demonstrated unique imaging findings.

Term explanation

Drug induced liver injury (DILI) is a diagnosis of exclusion of a rare adverse medication herbal reaction causing jaundice, liver failure, or even death. Roussel Uclaf Causality Assessment Method is a scoring system that assigns points for clinical, biochemical, serologic, and radiologic findings to demonstrate the likelihood of medication induced hepatotoxicity. Magnetic resonance cholangiopancreatography is a magnetic resonance imaging exam that produces detailed images of the hepatobiliary and pancreatic systems via a noninvasive manner.

Experiences and lessons

In order to diagnosis drug induced liver injury it is important to get a detailed history while implementing algorithms, causative assessment scales, histological findings, and imaging for all patients with unknown jaundice. DILI needs to be diagnosed early in order to prevent acute liver failure.