key: cord-0990088-dvcr7bty
authors: Rastogi, Mukul; Jagdish, Rakesh Kumar; Vij, Vivek; Bansal, Nalini
title: “Herbal Immune Booster-Induced Liver Injury in the COVID-19 Pandemic”
date: 2021-08-04
journal: J Clin Exp Hepatol
DOI: 10.1016/j.jceh.2021.07.015
sha: b54b620d513012abad542eaba714edd7281c09ce
doc_id: 990088
cord_uid: dvcr7bty

nan

We read with interest a case series of drug induced liver injury (DILI) cases in COVID 19 pandemic, entitled "Herbal Immune Booster-Induced Liver Injury in the COVID-19 Pandemic -A case series" by Nagral A et al (1) . We have observed two similar cases at our centre which were having complementary alternative medicine (CAM) associated liver injury during COVID 19 pandemic. Both the patients were having no prior comorbidity and all confounding diagnosis were ruled out. There were no history of any other new drug that could explain the presentation. Diagnosis of DILI was biopsy proven with Roussel Uclaf causality assessment method (RUCAM) score, was suggestive of DILI (table 1) . Both the patients has received giloy kadha and giloy preparations in high doses for COVID prevention. Competing etiologies were ruled out. Hepatitis serology (A/B/C/E), ceruloplasmin, and serology for epstein-barr/herpes simplex/cytomegalovirus, were negative and hepatic doppler ultrasound was normal. Autoimmune markers, showed ANA positive with high IgG levels in both cases and possibility of autoimmune hepatitis (AIH) was kept vs. DILI. Biopsy was done for both the cases and which was not suggestive of AIH and there were areas of perivenular necrosis and mild portal infiltrate, no interface hepatitis, paucity of plasma cells, no rosettes, relatively mild-moderate inflammatory infiltrate, predominantly with eosinophils, consistent with DILI , both our cases were biopsy proven.

The patient was treated with steroids in tapering doses, ursodeoxycholic acid (15 mg/kg), and liver biochemistry normalized after 10 -12 weeks. In the absence of other etiologies, bland cholestasis on liver biopsy, and roussel uclaf causality assessment method (RUCAM) score of 7 and 9 (second case has h/o of self-induced re-challenge, which resulted in fluctuating jaundice), consistent with DILI which was confirmed, with liver biopsy and AIH was ruled out.

Ayurvedic herb-related hepatotoxicity and liver injury can present as asymptomatic minor transaminase elevations, to acute liver failure requiring transplantation (2) . Tinospora cordifolia (TC)/Giloy is an herbaceous vine of the family menispermaceae, used as an immune-booster in the Indian subcontinent. DILI has emerged as a side effect after its prevalent use in the present time in various forms tablet, and kadha to prevent Covid 19 infection. The major misconception in Indian society is that "herbs are safe", which results indigenous use of the potentially lethal CAM/herbs in high doses. Often patient use them along with prescription drugs, without knowing the potential interactions and side effects of CAM. This results likely as a result of inhibition of drug metabolizing enzymes (e.g., cytochrome P450), or other unknown pathways, as CAM are not studied well so far, and underlying mechanisms are not known. Despite this, a standard system for prediction of drugherb interaction is still not present (3). In our cases, CAM were taken to boost immune response for COVID 19 prevention. The regulations of these CAM is not standardized , dosing are erratic , there is emergence of liver injury related to CAM intake during COVID as the excess use of CAM, may exceed the capacity of liver to metabolize them and results in toxicity and immune dysregulation, resulting in DILI. One should observe utmost precautions to use these remedies without supervision.

Herbal Immune Booster-Induced Liver Injury in the COVID-19 Pandemic -A case series

Comprehensive review of hepatotoxicity associated with traditional Indian Ayurvedic herbs

Herb-Drug Interactions and Hepatotoxicity

J o u r n a l P r e -p r o o f