P1136 - Elderberry Syrup: A Cause of Non-Immune-Related Liver Injury

Henry Egbuchiem, Bsc, MD, Joseph Amoah, MD, Alwatheq Alitelat, , Suhani Dalal, MD, Nkemputaife Onyechi, MD, Mohammed Mazumder, MD, FACG, Parvez Khambatta, MD, FACG
University Hospitals Geauga Medical Center, Chardon, OH

Introduction: Elderberry syrup (ES) a herbal extract of the Sambucus tree is used to boost the immunity when treating respiratory illnesses (common cold & influenza). ES activates pro-inflammatory cytokines(such as IL 1b, IL 6, IL 8, & TNF alpha), which provoke toxic liver changes leading to Drug-induced liver injury (DILI)[3]. Annual worldwide incidence of DILI is 15-20% per 100,000 people[9]. In 2014, the 1st prospective estimate of DILI in the US by 41 gastroenterologists in Delaware reported an incidence of 2.7 cases/100 000 adults with a 95% CI of 1.5-3.9[1]. Medications that cause liver damage are extensive. They include hormonal & herbal preparations, antibiotics, antiseizure & anti-tuberculous medications, methyldopa, & statins. Several case reports suggest a plausible relationship with the development of Autoimmune hepatitis after using ES. We present a patient with acute liver injury after recently starting ES. Even though her ANA level was elevated, further investigations revealed that she did not have autoimmune hepatitis.

Case Description/Methods: A 54 y/o F with a PMH of HTN, & hypothyroidism. Presented on account of abnormal LFT, progressive fatigue, postprandial nausea, indigestion, yellow skin, & 2 months of elderberry syrup use. Vital signs were normal. PE was only significant for sclera icterus. Laboratory investigations are below. CT of the Abd/pelvis showed liver and kidneys cysts (Fig A & Fig B). Liver MRI had periportal lesions (Fig 4). Liver biopsy showed mild to moderate portal & lobular hepatitis, mild interface activity, variable portal/periportal pericellular, & focal bridging fibrosis (matavir stage 2/4) in Fig C. Suggestive of liver injury secondary to medication/toxin exposure. The patient had supportive management.

Discussion: DILI is the leading cause of acute liver failure in the US. There are 2 mechanisms of DILI. The 1st is a predictable reproducible dose dependent intrinsic mechanism. The 2nd unpredictable idiosyncratic mechanism with a long latency period which is further divided into immune & nonimmune-mediated[8]. In Autoimmune hepatitis, there are increased liver enzymes and positive autoimmune markers. DILI presents with only elevated liver enzymes. Diagnosing DILI can be challenging, necessitating the use of objective clinical prediction scores. These include the Roussel Uclaf causality assessment (RUCAM), the Maria & Victorino (M&V), & the Naranjo Scale. Regardless of the score choice, liver biopsy should be used to exclude other causes of acute liver injury[10].




Disclosures:


Henry Egbuchiem, Bsc, MD, Joseph Amoah, MD, Alwatheq Alitelat, , Suhani Dalal, MD, Nkemputaife Onyechi, MD, Mohammed Mazumder, MD, FACG, Parvez Khambatta, MD, FACG. P1136 - Elderberry Syrup: A Cause of Non-Immune-Related Liver Injury, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.