P1069 - A Yellow Flower With Jaundice Power: A Case of Severe Liver Injury Attributed to Greater Celandine

Sunday, October 22, 2023

3:30 PM – 7:00 PM PT

Location: Exhibit Hall

Has Audio

Presenting Author(s)

Sydney Power, MD

University of North Carolina
Chapel Hill, NC

Sydney Power, MD¹, A Sidney. Barritt, MD, MSCR²
¹University of North Carolina, Chapel Hill, NC; ²University of North Carolina Chapel Hill, Chapel Hill, NC

Introduction: Greater Celandine (GC) is a flowering plant indigenous to Eurasia that is used in homeopathy for nausea and biliary colic. To date, hepatotoxicity from GC has only been described in Europeans. We present a case of well characterized drug induced liver injury (DILI) from GC in the United States.

Case Description/Methods: A 72-year-old male with diabetes and hyperlipemia developed malaise, dark urine, and painless jaundice. He had no history of liver disease, abnormal liver tests, alcohol, or substance use. His medications were acetaminophen-hydrocodone, aspirin, atorvastatin, glipizide, lantus, and metformin. Liraglutide was started 2 weeks prior. He also intermittently used several herbal and dietary supplements (HDS) including Nux Vomica, Arnica Montana, and GC, up to 30 cc QID over the prior 3 months for abdominal pain and nausea.

Vials and exam were unremarkable besides jaundice. Labs were a total bilirubin 12.3 mg/dL, alkaline phosphatase 507 IU/L, ALT 974 IU/L, AST 1119 IU/L consistent with a hepatocellular liver injury (R value 5.8). Viral and autoimmune studies were negative. Imaging was normal. Liver biopsy showed hepatitis with eosinophils; grade 3, stage 1. DILI was suspected and he stopped all HDS products. Liver enzymes normalized within 2 months (table 1). The case was presented to the Drug Induced Liver Injury Network and adjudicated by a panel of experts to be “highly likely” DILI from GC.

Discussion: GC may help nausea and biliary colic due to antispasmodic effects of alkaloids in leaf extracts. GC hepatotoxicity is described (likelihood score B) in European patients and resembles acute hepatitis with hepatocellular pattern of liver injury. Toxicity occurs within 1-6 months and rapidly resolves after discontinuation.

This case was challenging to establish causality for DILI due to confounding factors. He recently started liraglutide, was taking known hepatotoxic medications, and used several HDS. Despite the temporal association of liraglutide initiation and liver injury, DILI from GLP-1 agonists is quite rare (likelihood score E). The other medications must be taken in high doses to cause DILI and he had tolerated these for years. Nux Vomica and Arnica Montana have no known cases of hepatotoxicity.

As the incidence of HDS related DILI is rising, providers must assess for HDS use. Gastroenterologists should be aware of GC given its use for common gastrointestinal symptoms and provide counseling on the potential risks of this herbal remedy.

Labs and reference range	10/7/21 Admission (HDS products stopped)	10/12/21 Discharge	10/18/21	11/22/21	7/7/22
Albumin (3.7-4.7 g/dL)	2.5	2.2	3.3	3.7	4.4
Alkaline Phosphatase (44-121 IU/L)	507	439	305	111	92
ALT (0-44 IU/L)	974	549	106	12	16
AST (0-40 IU/L)	1119	312	49	12	17
Direct Bilirubin (0-0.4 mg/dL)		10.7	2.85	0.69	0.28
Total Bilirubin (0-1.2 mg/dL)	12.3	14.7	3.9	1.3	0.9
Total Protein (6-8.5 g/dL)			7	6.7	6.7
Platelets (150-450x10E3/uL)	165	211			184
INR (0.9-1.2)	1.1	1.0			1.0

Table: Table 1 – Liver Tests

Disclosures:

Sydney Power indicated no relevant financial relationships.

A Barritt: Abbott – Consultant. Merck – Advisory Committee/Board Member. Target RWE – Consultant.

Sydney Power, MD¹, A Sidney. Barritt, MD, MSCR². P1069 - A Yellow Flower With Jaundice Power: A Case of Severe Liver Injury Attributed to Greater Celandine, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.