Hindawi Publishing Corporation Case Reports in Hepatology Volume 2013, Article ID 965092, 4 pages http://dx.doi.org/10.1155/2013/965092 Case Report Chinese Skullcap in Move Free Arthritis Supplement Causes Drug Induced Liver Injury and Pulmonary Infiltrates Renumathy Dhanasekaran, 1 Victoria Owens, 2 and William Sanchez 1 1 Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA 2 Department of Pathology, Mayo Clinic, Rochester, MN 55905, USA Correspondence should be addressed to William Sanchez; sanchez.william@mayo.edu Received 28 January 2013; Accepted 19 March 2013 Academic Editors: G. H. Koek, H. H. Lin, and H. Nagahara Copyright © 2013 Renumathy Dhanasekaran et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Herbal medications are being increasingly used by the American population especially for common conditions like arthritis. Tey have been reported to cause adverse efects, including signifcant hepatotoxicity, but reporting remains sporadic. We report here a patient who developed drug induced liver injury following the intake of Move Free, which is an over-the-counter arthritis supplement. We propose that Chinese skullcap, which is one of the herbal ingredients of the medication, is responsible for the adverse event. Tere was a strong temporal association between the intake of supplement and onset of symptoms, and also there have been a few recent case reports implicating the same component. A unique observation in our case is the occurrence of pulmo- nary infltrates simultaneously with the hepatotoxicity, and this side efect has not been well documented before. Both the hepatic and pulmonary complications completely resolved over few weeks afer the patient stopped taking the medication. Since these sup- plements are readily available over the counter, we feel that it is important to document possible adverse outcomes to raise awareness in the medical community and also among patients. 1. Introduction More than a third of Americans use herbal medications for various purported benefcial efects and most of them do not disclose their use to physicians [1, 2]. Tese medications are considered by patients to be safe as they are of natural origin. Unfortunately they can cause serious adverse efects. Te process of FDA regulation of these supplements is less rig- orous than that for drugs, so their adverse efects are not well documented. Nonetheless it is important to document cases of serious adverse outcomes related to herbal supplements, both to raise awareness and hopefully to prevent recurrence. We report here a case of hepatotoxicity related to use of an over-the-counter arthritis supplement. 2. Case Report A 62-year-old Caucasian female with a history of diabetes mellitus was hospitalized for acute onset of shortness of breath. She was found to be hypoxic, and chest X-ray showed bilateral interstitial infltrates. She was incidentally found to have abnormal liver tests in the form of elevated aminotrans- ferases and hyperbilirubinemia (Figure 1). Te patient did not give a history of prior liver disease, did not drink alcohol, and had no risk factors for acute viral hepatitis. Her most recent previous liver tests (from 3 years ago) had been com- pletely normal. Physical examination revealed jaundice but no splenomegaly, asterixis, or other stigmata of chronic liver disease. Te following tests were negative or normal on eva- luation—viral hepatitis serologies, serologic markers of autoimmune hepatitis, serology for Lyme disease, HIV, CMV, and EBV serologies. Serum ceruloplasmin was normal, and testing for alpha1 antitrypsin defciency was negative. Ultra- sound of the abdomen demonstrated fatty infltration with no evidence of portal hypertension and no evidence of biliary ductal obstruction. A detailed medication history was obtained to identify potentially hepatotoxic medications. Te patient reported using metformin at a stable dose on a daily basis for several years. Two weeks prior to hospitalization, she had started