Herbal Immune Booster-Induced Liver Injury in the COVID-19 Pandemic - A Case Series
Authors
Aabha Nagral
Department of Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, India
Kunal Adhyaru
Department of Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, India
Omkar Rudra
Department of Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, India
Amit Gharat
Department of Gastroenterology, Apollo Hospital, Navi Mumbai, India
Sonal Bhandare
Department of Pathology, Jaslok Hospital and Research Centre, Mumbai, India
Keywords:
tinospora cordifolia, Giloy, drug induced liver injury, drug-induced autoimmune hepatitis, herb induced liver injury
Abstract
The COVID-19 pandemic has resulted in widespread use of complementary and alternative medicines. Tinospora cordifolia is a widely grown shrub which has been commonly used in India’s traditional system of Ayurveda for its immune booster properties and has been extensively used as prophylaxis against COVID-19. Six patients (4 women, 2 men) with a median (IQR) age of 55 years (45–56) and with an history of Tinospora cordifolia consumption presented with symptoms of acute hepatitis during the study period of 4 months in the COVID-19 pandemic. The median (IQR) duration of Tinospora cordifolia consumption was 90 days (21–210). The median (IQR) peak bilirubin and AST were 17.5 mg/dl (12.2–24.9) and 1350 IU/ml (1099-1773), respectively. The patients had either a definite (n = 4) or probable (n = 2) revised autoimmune hepatitis score with an autoimmune pattern of drug-induced liver injury on biopsy. Four of these patients (all women) had underlying silent chronic liver disease of possible autoimmune etiology associated with other autoimmune diseases – hypothyroidism and type 2 diabetes mellitus. One of the three patients treated with steroids decompensated on steroid tapering. The other five patients had resolution of symptoms, liver profile, and autoimmune serological markers on drug withdrawal/continuing steroid treatment. The median (IQR) time to resolution from discontinuing the herb was 86.5 days (53-111). Tinospora cordifolia consumption seems to induce an autoimmune-like hepatitis or unmask an underlying autoimmune chronic liver disease, which may support its immune stimulant mechanism. However, the same mechanism can cause significant liver toxicity, and we recommend that caution be exercised in the use of this herb, especially in those predisposed to autoimmune disorders. Besides, in patients presenting with acute hepatitis, even in the presence of autoimmune markers, a detailed complementary and alternative medicine history needs to be elicited.
Keywords: tinospora cordifolia, Giloy, drug induced liver injury, drug-induced autoimmune hepatitis, herb induced liver injury
Abbreviations: AIH, Autoimmune hepatitis; ALT, Alanine Transaminase; ASMA, Anti-Smooth Muscle Antibody; AST, Aspartate Transaminase; CAM, Complementary and Alternative Medicines; COVID-19, Coronavirus Disease of 2019; DILI, Drug-Induced Liver Injury; IgG, Immunoglobulin G; IQR, Inter Quartile Range; LFT, Liver Function Tests; RUCAM, Roussel Uclaf Causality Assessment Method; SMT, Standard medical treatment; TC, Tinospora cordifolia; ULN, Upper Limit of Normal; USG, Ultrasonography
Author Biography
Aabha Nagral, Department of Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, India
Department of Gastroenterology, Apollo Hospital, Navi Mumbai, India
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