sinensis, requiring orthotopic liver transplantation[13,16]

sinensis, requiring orthotopic liver transplantation[13,16]. The liver biopsy obtained in our patient who took Hydroxycut showed multi-lobular necrosis consistent with acute toxic necrosis and fulminant hepatitis. supplements. Hydroxycut (MuscleTech, Mississauga, Ontario, Canada) (case 1) and Herbalife (Herbalife, Los Angeles, USA) (cases 2 and 3) supplements were the suspected culprits of acute liver injury. Hydroxycut is a popular dietary supplement consisting of a variety of herbal mixtures that claims to enhance the weight loss process[2]. Acute liver injury associated with Hydroxycut use has been previously reported, but only one case had liver biopsy data Micafungin showing cholestasis and portal inflammation[3-6]. Similarly, Herbalife weight-loss dietary products are popular supplements consisting of a variety of herbal mixtures that claim to facilitate weight reduction[7]. Cases of acute liver injury after consumption of Herbalife products have been previously reported, with two patients developing fulminant liver failure requiring liver transplantation. The first patient survived while the second died[8-11]. In all of our cases, we were able to demonstrate drug-induced acute liver injury on liver biopsy specimens. == CASE REPORT == == Case 1 == A 31-year-old woman presented to our hospital complaining of 2-wk history of fatigue, jaundice, and nausea. She denied any prior medical or surgical conditions, family history of liver disease, and acetaminophen or prescription medication use. She further denied history of blood transfusion, tattoo, alcohol use, or recreational drug use. She had been taking Hydroxycut for one year to enhance her weight loss. She had been taking the recommended dose of 2 tablets twice a day. The patient was afebrile with normal hemodynamics upon presentation. Her physical examination was remarkable for generalized jaundice, scleral icterus, and mild upper quadrant tenderness to palpation without rebound or guarding. Initial laboratory studies were significant for serum aspartate aminotransferase (AST) level of 1407 U/L (normal range 15-41), serum alanine aminotransferase (ALT) level of 1278 U/L (normal range 7-35), serum alkaline phosphatase of 256 U/L (normal range 38-126), serum total bilirubin (TB) of 7.1 mg/dL (normal range 0.2-1.2), and international normalized ratio (INR) of 1 1.3 I/U (normal range 0.8-1.2). Given these findings, patient was admitted to the hospital for a higher level of care. Standard blood tests were negative for hepatitis A, B, C, E, Ebstein Barr virus (EBV), cytomegalovirus (CMV), human immunodeficiency virus (HIV), antinuclear antibody, anti-smooth muscle antibody, anti-liver/kidney microsomal antibody, alpha-1-antitrypsin deficiency, and anti-mitochondrial antibody. Serum acetaminophen and urine toxicity screens were negative. Serum ceruloplasmin, ferritin, iron studies, and immunoglobulins were all within the normal range. Right upper quadrant ultrasound showed diffuse echogenicity of the liver. Liver biopsy was performed and showed multi-lobular necrosis consistent with acute toxic necrosis and fulminant hepatitis (Figure1). == Figure 1. == Liver biopsy showed extensive patchy areas of multilobular necrosis with only bile ducts remaining, extensive ductal metaplasia, Micafungin severe lymphocytic and macrophages infiltration of portal tracts and lobular parenchyma and patchy plasma cell infiltrates. Histological changes were consistent with acute troxis necrosis and fulminant hepatitis. A: Liver lobules showing massive necrosis with only bile Micafungin ducts remaining (hematoxiline and eosin stain 52); B: Lymphocytic infiltration of portal tract and lobular parenchyma (hematoxiline and eosin stain 130); C: Liver lobular necrosis with macrophages cleaning the debris (CD68 stain 130); D: Ductal metaplasia. Lymphocytic infiltration in the sinusoids (CAM5.2 stain 260); E: High power, lymphocytes destroying hepatocytes (CAM5.2 stain 520); F: Lymphocyte eating hepatocytes in a liver parenchyma (troxis necrosis), arrow showing immunological synapses (Electron microscopy 15000). The patients liver function tests peaked 4 d after admission with serum AST level of 1613 U/L, ALT level of 1227 U/L, serum alkaline phosphatase Rabbit Polyclonal to PFKFB1/4 of 268 U/L, serum TB of 10.5 mg/dL,.