Turmeric Dietary Supplement‐Induced Autoimmune Hepatitis: A Case Report

Abstract

Autoimmune hepatitis (AIH), a chronic disorder of unknown etiology characterized by hypergammaglobulinemia and autoantibody positivity, is induced by drug injury in a minority of cases. Herbal supplements are increasingly being recognized as a potential cause of drug‐induced hepatitis (DIH). We report here on a case of drug‐induced, autoimmune hepatitis (DIAIH) attributable to ingestion of a turmeric dietary supplement. Autoimmune hepatitis (AIH) was diagnosed, as per Hennes criteria (score = 7 of 8 total), in a 76‐year old Caucasian woman presenting with an asymptomatic elevation in liver transaminases (alkaline phosphatase and bilirubin, normal). Diagnostic work up was notable for: 1) elevated IgG levels (1.3 X ULN); 2) positive antibody titers (> 1:80) for atypical pANCA and smooth muscle actin; 3) liver histology on biopsy compatible with AIH, and 4) exclusion of viral hepatitis. The patient's medical records, while not including mention of turmeric dietary supplement use, did document concurrent use of 15 other prescription or over the counter (OTC) medications which remained unchanged throughout the course of transaminase elevations. Attribution of AIH to turmeric supplementation, which the patient had begun 10‐months prior to her diagnosis, was elucidated by the patient, who stopped turmeric supplementation 2 months after her AIH diagnosis upon reading of a possible risk of turmeric‐induced hepatitis. Within 1 month of turmeric discontinuation, transaminase levels, which had risen to a maximum of 4–8 X ULN (for AST and ALT, respectively) began to decline and returned to normal within a year, where they have remained until the present time (3 years). Assessment of updated RUCAM drug‐induced hepatitis (DIH) criteria (Danan et al, Int J Mol Sci 17:2016) yielded a score of 6 (of 13 total, with ≥9 being highest category of attribution [“highly probable”]), consistent with probable attribution of turmeric use to hepatic injury in this patient. As is common in situations of supplement induced side‐effects, the actual product, which the patient had taken as directed on the label, was not identified or available for testing. In summary, this case illustrates several key points: 1) consumers and healthcare professionals should be aware that turmeric supplements, a top selling herbal in the US, can be associated with hepatoxicity, including induction of AIH; 2) the role of turmeric, concomitant medications, and/or potential contaminants in mediating supplement‐induced liver damage cannot be assessed at present; and 3) open conversations about OTC supplement use between healthcare providers and patients remains imperative to ensure delivery of high quality practice, particularly in situations of increased risk of drug‐supplement interactions.Support or Funding InformationNIH‐NCCIH#R34 AT007837