Hepatitis associated with Chinese herbs C.A. McRae a , K. Agarwal a , D. Mutimer b and M.F. Bassendine a Traditional Chinese herbal medicines are widely available in Western society and are popular as a form of ‘natural’ alternative medicine. Their use is increasing, as they are perceived to be free of side effects, but they remain largely unregulated. We describe two patients who suffered severe hepatitis, one of whom died, after taking Chinese herbal remedies for minor complaints. We also review the English-language literature on hepatitis associated with Chinese herbs. Two products appear to be implicated frequently: Jin bu huan was taken by 11 patients, and Dictamnus dasycarpus was taken by six patients, including both fatal cases. It is difficult to provide conclusive evidence of what caused hepatitis, as these products are mixtures that may contain adulterants. These cases highlight not only the potential dangers of these products to consumers but also the need for greater control of their manufacture and use. Eur J Gastroenterol Hepatol 14:559–562 & 2002 Lippincott Williams & Wilkins European Journal of Gastroenterology & Hepatology 2002, 14:559–562 Keywords: hepatitis, liver failure, traditional Chinese herbal medicine a Freeman Hospital Liver Unit, Newcastle upon Tyne Hospitals Trust, Newcastle and b Queen Elizabeth Hospital, Birmingham, UK Correspondence to Professor M.F. Bassendine, Centre for Liver Research, 4th Floor, William Leech Building, The Medical School, Framlington Place, Newcastle Upon Tyne NE2 4HH, UK Tel: +44 191 222 6995; fax: +44 191 222 0723; e-mail: M.Bassendine@ncl.ac.uk Received 24 August 2001 Revised 2 October 2001 Accepted 5 December 2001 Introduction Herbal medicine is being practised increasingly widely in the West. Chinese herbalism is the most prevalent of the ancient traditions used in Europe [1]. Although benefits are generally unproven, the industry is now large and concerns have been voiced about the absence of regulation in this sector and lack of awareness of the potential harm of herbal remedies. In response, in the UK pharmacosurveillance was extended in 1996 to include reporting of suspected adverse reactions to unlicensed herbal medicines, and the European Com- mission is now working towards a statutory framework on herbal medicines to enable improvement in quality standards. We report two cases, one fatal, of severe hepatitis following the ingestion of Chinese herbal remedies, and we review the literature on hepatitis associated with these medicines. Case report 1 A 31-year-old woman was prescribed an infusion of Chinese herbal roots for arthralgia. She discontinued the preparation after 5 weeks following the develop- ment of nausea, anorexia, jaundice and dark urine. At presentation 1 week after the onset of her symptoms, she was jaundiced but not encephalopathic. Bilirubin was 140 ìmol/l, alanine transaminase (ALT) was 2930 IU/l and prothrombin time was 16 s. ALT peaked at 3874 IU/l 1 week after admission. Bilirubin climbed to 547 ìmol/l 3 weeks after presentation, as did the prothrombin time, which peaked at 24 s. The patient had taken no other medication (except the oral contraceptive for 11 years), and she did not abuse alcohol. She had no risk factors for viral hepatitis and no past history or family history of liver problems. Viral screens for hepatitis A, B, C and E were negative. Metabolic screens for Wilson’s disease, Æ-1 anti-trypsin deficiency and haemochromatosis were also negative, as were autoantibodies. Transjugular liver biopsy showed acute hepatitis with bridging necrosis and eosinophils in the inflammatory infiltrate, consistent with a hyper- sensitivity reaction to drugs. Following initial improve- ment, the condition deteriorated with worsening liver function tests and a fall in haemoglobin, and the patient developed a pyrexia that was consistently culture negative and failed to respond to broad- spectrum antibiotics. A bone marrow aspirate showed haemophagocytosis and red cell aplasia, which was treated with intravenous immunoglobulin [2]. Follow- ing a 5-day course, the pyrexia settled and the liver and haematological parameters improved. On discharge from hospital 8 weeks after presentation, bilirubin had fallen to 120 ìmol/l and ALT had fallen to 62 IU/l. Six months after presentation, liver function tests returned to normal, and they remain normal 12 months later. Case report 2 A 32-year-old man took nine doses of Chinese herb roots for multiple lipomas. While taking the treat- ment, he became unwell with diarrhoea and nausea, but he persisted until he had finished the prescribed course. On discontinuing the medication, he contin- ued to feel unwell and developed dark urine and jaundice. On admission to hospital 4 weeks later, the patient was Case report 559 0954–691X & 2002 Lippincott Williams & Wilkins