Case report 1135 Fulminant hepatitis during self-medication with hydroalcoholic extract of green tea Romain Gloro a , Isabelle Hourmand-Ollivier a , Brigitte Mosquet b , Laurent Mosquet a , Pierre Rousselot c , Ephrem Salame ´ d , Marie-Astrid Piquet a and Tho ˆ ng Dao a Despite an ancient reputation for potential phytothera- peutic effects and innocuity, traditional herbal medicine has previously been implicated in severe adverse events. Exolise is an 80% ethanolic dry extract of green tea (Camellia sinensis) standardized at 25% catechins ex- pressed as epigallocatechin gallate, containing 5–10% caffeine. It has been available in France, Belgium, Spain and the United Kingdom since 1999, as an adjuvant therapy for use in weight loss programmes. In various studies, green tea has to date been considered useful for its potential hepatic protective properties. In this study, we report a case of fulminant hepatitis during self-medication with Exolise, requiring liver transplantation. Eur J Gastroenterol Hepatol 17:1135–1137  c 2005 Lippincott Williams & Wilkins. European Journal of Gastroenterology & Hepatology 2005, 17:1135–1137 Keywords: exolise, fulminant hepatitis, green tea, hydroalcoholic extract of green tea, liver transplantation a Service d’He ´ patogastroente ´ rologie et de Nutrition, b Centre Re ´ gional de Pharmacovigilance, c Service d’Anatomopathologie and d Service de Chirurgie Digestive et de transplantation He ´ patique, CHU Co ˆ te de Nacre, Caen, France. Correspondence to Romain Gloro, Service d’He ´ patogastroente ´ rologie et de Nutrition, CHU Co ˆ te de Nacre, 14033 Caen, France. Tel: + 33 2 31 06 45 39; e-mail: gloro-r@chu-caen.fr Received 14 January 2005 Accepted 28 June 2005 Case report On 30 April 2001, a 48-year-old woman consulted with jaundice, which had appeared 4 days earlier. Her previous medical and surgical history were unremarkable. She admitted to drinking 30 g alcohol a day for the past 10 years. She had not been receiving any regular medical treatment, but she had been on self-medication during the 2 months before admission. Initially, on 11 March she went on a diet and began taking Exolise (four capsules a day). On 17 April she drank one dose of a food supplement used for sunbathing (Bronz’age; Robert Schwartz Laboratory, Illkirch Graffenstaden, France), which contained red fruit juice, fructose, inulin, acerola, b-carotene, lemon extract rich in bioflavonoids, vitamins C and E, pantothenic acid, sorbic acid and potassium benzoic acid. She stopped Bronz’age the day after, complaining of hearing voices and vertigo, and was treated by her general practitioner, with 30 mg a day of nicergoline (Sermion), 50mg a day of piribedil (Trivas- tal), and 60 mg a day of prednisolone (Solupred). All drugs were stopped on 23 April because of epigastric pain and fatigue, followed by jaundice, pale stool and dark urine 3 days later. She took only 1 g paracetamol the day after the onset of jaundice. There was no pruritus. Oral examination was otherwise unremarkable (no transfusion, drug addiction, travel to any endemic country, viral risk factor, or mushroom consumption). On physical examina- tion there were no signs of ascites, hepatomegaly, splenomegaly, no stellate spider, collateral vein, excoria- tion, flapping tremor, or alteration of consciousness. Arterial pulse was 85 bpm, arterial pressure 144/ 78 mmHg, and temperature 37.51C. Her weight was 60 kg, height was 158 cm and body mass index was 24. Laboratory tests revealed a marked increase in aspartate aminotransferase: 140 times the upper limits of normal (ULN), alanine aminotransferase: 102 ULN, and choles- tasis (total serum bilirubin level of 473.2 mmol/l, con- jugated 405.6 mmol/l, g-glutamyl transpeptidase 3.3 ULN), with no increase in alkaline phosphatase activity. Blood count was normal, prothrombin time 59%, factor V 100%, serum albumin 30 g/l. Viral markers (anti-hepatitis A virus antibodies type IgM, anti-hepatitis C virus antibodies, hepatitis B surface antigen, anti-hepatitis B core antibodies, cytomegalovirus antibodies, herpes simplex virus antibodies, Epstein–Barr virus antibodies, as well as specific hepatitis C virus RNA and hepatitis B virus DNA) were negative. Autoantibody tests were also negative (antimitochondrial, antinuclear, anti-liver/kidney microsomal, and anti-smooth muscle antibodies). Ultra- sound and Doppler examination showed no evidence of biliary tract obstruction, Budd–Chiari syndrome, or portal vein thrombosis. Symptoms were unlikely to be caused by either hepatic ischaemia or cardiac deficiency as there was no previous history of cardiac disease, and arterial pressure, electrocardiogram and chest X-ray were all normal. On 9 May the patient was admitted to hospital for hepatocellular insufficiency with alteration of con- sciousness, flapping tremor and factor V, which decreased to 49%. Intravenous N-acetyl-cysteine (Fluimucil) was routinely administered despite the lack of detectable 0954-691X  c 2005 Lippincott Williams & Wilkins Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.