Case Presentation: A 40 year old previously healthy female was incidentally found to have elevated transaminases on routine lab work. She was sent to our hospital for further evaluation. On admission, she complained of fatigue, right sided abdominal discomfort, and jaundice of a few weeks. She denied taking prescription medications but reported taking a supplement called Apetamin Cyproheptadine Lysine and Vitamin Syrup purchased over the internet. She started the supplement 6 weeks prior to enhance her figure and gain weight in her buttock and thighs. She revealed she consumed more than the 5mL recommended daily dose and instead drank from the bottle to increase effects. She learned of the drug on social media, where it is promoted as a nonsurgical body augmentation alternative. Lab work on presentation was significant for aspartate aminotransferase (AST) 838 Units/L, alanine transaminase (ALT) 997 Units/L, and alkaline phosphate 90 Units/L, smooth muscle antibody 5 times the upper limit of normal (108 Units), IgG immunoglobulin 2 times the upper limit of normal (3162 mg/dL), concerning for autoimmune hepatitis. Hepatitis A IgM, Hepatitis B Core IgM, Hepatitis B Surface Antigen, and Hepatitis C Antibody, HIV, CMV, EBV, QuantiFERON, and mitochondrial antibody were negative; iron and ceruloplasmin normal. Right upper quadrant ultrasound showed normal portal and hepatic veins and no biliary dilatation. Liver biopsy showed active hepatitis with increased fibrosis, cholestasis cholangial metaplasia, and histologic features of lymphoplasmacytic inflammation, lobular inflammation and disarray, hepatocyte necrosis, and multinucleated hepatocytes. Findings indicated drug induced autoimmune hepatitis (DIAIH). Prednisone 40mg was started followed by rapid improvement in liver function. She was discharged day 5 with down trending transaminases, counselled to stop Apetamin supplement, and prescribed Prednisone. At 1 week discharge follow up, she reported improvement in symptoms; AST/ ALT was 104 and 247, respectively, and Azathioprine 50mg was started. At three months transaminases normalized, and prednisone was tapered.
Discussion: We report a rare case of Apetamin Cyproheptadine Lysine and Vitamin Syrup ingestion triggering DIAIH, a hepatoxicity characterized by the presence of antinuclear or anti-smooth muscle antibody. Drugs associated with DIAIH include antimicrobials (nitrofurantoin, minocycline), interferon, infliximab, and statins. The active ingredient in Apetamin, Cyproheptadine, is linked to hepatitis in case reports, but is not known to induce an autoimmune reaction. The supplement contains 2mg of cyproheptadine per 5mL serving; other components include L-lysine, Nicotinamide, Dexpanthenol, Thiamine, and Pyridoxine. The drug is not FDA approved for use in the United States. This unregulated supplement is easily purchased illegally over the internet and social media and is marketed to women for body augmentation.
Conclusions: The popularity of cyproheptadine-based weight gain supplements is concerning given the severe risks and limited knowledge in the general and medical community. This case highlights the changing environment in which medications are advertised, distributed, and sold. Social media is a powerful tool to selectively target and lure patients to purchase drugs that can negatively impact health. It is important health care provers be familiar with such trends and side effects in order to effectively counsel and treat patients.