Case report 507 Herb-induced hepatitis by Teucrium polium L.: report of two cases and review of the literature Savvoula Savvidou a , John Goulis a , Ignatios Giavazis a , Kalliopi Patsiaoura b , Prodromos Hytiroglou c and Constantine Arvanitakis a Herbal medicinal products are being increasingly used throughout the world. Herbal ‘remedies’ are, however, not risk free and many cases of hepatotoxicity have been reported. Teucrium polium grows mostly in the Mediterra- nean basin and is popular, because of hypoglycemic and hypolipidemic properties. We report two cases of T. polium- induced hepatitis in Greek female patients, who used the plant’s extract to control the cholesterol levels. Both patients presented with very high aminotransferases after consuming herbal tea for 2 or 3 months. One patient also developed jaundice. Histologic examination of liver biop- sies showed hepatitis with moderate or severe necroin- flammatory activity. Discontinuation of the herbal remedy resulted in normalization of the liver enzymes in both patients. Our findings, and those of other authors, suggest that T. polium may not be safer than T. chamaedrys and T. capitatum, which have also been reported to occasionally cause hepatotoxicity. Eur J Gastroenterol Hepatol 19:507–511  c 2007 Lippincott Williams & Wilkins. European Journal of Gastroenterology & Hepatology 2007, 19:507–511 Keywords: drug-induced hepatitis, medicinal herbs, Teucrium a 4th Department of Internal Medicine, Hippocration General Hospital of Thessaloniki, Medical School of Aristotle University, b Department of Pathology, Hippocration General Hospital of Thessaloniki and c Department of Pathology, Medical School of Aristotle University of Thessaloniki, Thessaloniki, Greece Correspondence to John Goulis, MD, 59 Konstantinopoleos Street, 54642 Thessaloniki, Greece Tel: + 302310892040; fax: + 302310992940; e-mail: igoulis@med.auth.gr Received 2 May 2006 Accepted 14 August 2006 Introduction In recent years, there is a growing trend for alternative or traditional medicine. The increasing popularity of herbal medicinal products in different countries has been demonstrated by a number of studies [1]. This, along with the fact that a large number of herbal remedies are being used in various parts of the world without having first been submitted to rigorous scientific testing, has resulted in many cases of hepatotoxicity [1–4]. A recent example comes from France [5], where Teucrium chamaedrys, the so-called germander, caused an epidemic of hepatitis that led to the prohibition of all preparations that contained it. T. polium L., a related species, which grows mostly in the east Mediterranean basin, appears to be a new threat. In this article, we report two cases of T. polium-induced hepatitis and review the literature. Case reports Case 1 A 47-year-old Greek woman was admitted to hospital because of high aminotransferase values. The patient had no symptoms and was in good general condition. She reported having a history of mild diabetes mellitus and hypercholesterolemia. She had consumed herbal tea for 3 months before admission, in order to control glucose and cholesterol levels. History of smoking or alcohol abuse was negative. On admission, physical examination was normal. Ultra- sonography of the upper abdomen showed a homoge- neous liver, normal in size and no signs of intrahepatic and extrahepatic biliary dilatation. Aspartate transaminase was 433 IU/l (10–31) and alanine transaminase 677 IU/l (10–34). Other abnormal laboratory values were as follows: total bilirubin 1.82 mg/dl (0.3–1.2), conjugated bilirubin 0.21 mg/dl (0–0.2), alkaline phosphatase 132IU/l (30–120), g-glutamyl-transferase 57 IU/l (0–38), glucose 151 mg/dl (70–110) and total cholesterol 237 mg/dl (120–200). Other laboratory tests ranged within normal levels [serum albumin 4.4 g/dl (3.5–5.2), international normalized ratio 0.73, white blood cells 7.9 K/ml with neutrophils 59.4%, lymphocytes 27.3%, monocytes 10.3% and eosinophils 2.7%]. Serologic testing for hepatotropic viruses (hepatitis viruses A, B and C, Epstein–Barr virus, cytomegalovirus, herpes viruses, human immunodefi- ciency virus, adenoviruses, parvo B19) was negative. The immunologic profile revealed no pathological auto- antibodies (antinuclear antibodies, antismooth muscle antibodies, antimitochondrial antibodies, antiliver– kidney-microsomes type 1 antibodies). Ceruloplasmin, a1-antitrypsin and ferritin levels were normal. On the fifth day after admission, a needle liver biopsy was performed. Histological examination showed moderate portal inflammatory infiltrates, mainly composed of lymphocytes and plasma cells, and small number of eosinophils. Mild periportal necrosis was also seen. Bile 0954-691X  c 2007 Lippincott Williams & Wilkins Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.