Case Presentation: A 69 year old male with no past medical history presented to the hospital with significant generalized pruritus. 3 weeks prior to presentation, the patient started taking a daily dose of a turmeric supplement. About a week later, he began developing a slow but progressive generalized pruritus, scleral icterus, pale stools, darkening urine and jaundice. His pruritus became so severe it prevented him from sleeping and eventually caused him to come to the emergency room. On exam, he was afebrile without confusion or abdominal tenderness. His liver function tests (LFT’s) showed alkaline phosphatase of 241 U/L, AST 95 U/L, ALT 66 U/L and total bilirubin of 13.0 mg/dL. CT abdomen/pelvis showed hepatic steatosis but was otherwise unrevealing. He was admitted to the hospital medicine service for further workup of acute onset hyperbilirubinemia and severe pruritus requiring IV diphenhydramine. His turmeric was discontinued on admission. HIV, EBV and Hepatitis A, B and C were all negative for acute infection. ANA was positive (1:160) but anti-smooth muscle and anti-mitochondrial antibodies were negative. MRCP was normal and without any signs of obstruction. An ultrasound guided liver biopsy was taken. The patient’s pruritus improved with initiation of ursodiol and cholestyramine, and he no longer required IV diphenhydramine. His LFT’s mildly improved to alkaline phosphatase 210 U/L, AST 80 U/L, 60 U/L and direct bilirubin of 12.7 mg/dL. Given this, he was discharged with outpatient follow up. His biopsy results subsequently finalized and were consistent for drug induced liver injury (DILI). Because his only new medication was his turmeric supplement, this was thought to be the etiology of his DILI. He was started on a prolonged prednisone taper over 8 weeks. On follow up after completion of steroid regimen, patient’s symptoms completely resolved and LFT’s showed alkaline phosphatase of 114 U/L, AST 49 U/L, ALT 55 U/L and total bilirubin of 1.2 mg/dL.
Discussion: Over 1,000 agents are recognized to cause DILI by the National Institute of Health, and herbal supplements account for 20% of reported cases. Turmeric, often used medicinally for its purported anti-inflammatory effects, is generally well tolerated but is a supplement known to cause DILI. Typically, onset of injury occurs weeks to months after initiation of turmeric supplementation. Patients often present with the insidious development of fatigue, anorexia, nausea, dark urine and jaundice. Serum aminotransferases are often elevated in a hepatocellular pattern (though was cholestatic in our case). The resulting liver injury can be severe and can progress to acute liver failure rarely. Fortunately, most cases are self-resolving with turmeric cessation though steroids are often prescribed for severe presentations.
Conclusions: Dietary supplements including turmeric, are often seen as benign, but they are a common cause of DILI.