Acute Liver Injury After Long-Term Herbal "Liver Cleansing" and "Sleep Aid" Supplement Use.

BACKGROUND: Acute liver injury is reported in association with toxins, pharmaceuticals, and viral infections. Increasingly prevalent are cases of herbal- and dietary supplement-related hepatotoxicity. Early recognition of this potentially life-threatening complication by emergency care providers leads to more appropriate management and disposition. CASE REPORT: A 53-year-old woman presented to the emergency department with a 3-day history of jaundice and increased abdominal girth after a month-long use of a combination herbal "liver-cleansing" compound and a nightly herbal "sleep aid." The "Liver Detoxifier and Regenerator" listed multiple constituents, including concentrated scute root and turmeric root; "Restful Sleep" listed multiple constituents, including valerian. Emergency department evaluation revealed marked hyperbilirubinemia with liver enzyme elevations indicative of cholestatic jaundice. Imaging studies, including ultrasound and abdominal magnetic resonance imaging, revealed hepatomegaly and steatosis without biliary dilatation; a biopsy specimen was obtained, and the results were consistent with drug-induced liver injury. The patient's liver function abnormalities gradually improved with discontinuation of the products as well as a tapered course of corticosteroid therapy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A significant proportion of the U.S. adult population uses herbal and dietary supplements. Most patients do not discuss nonprescription medication use with their providers and many physicians will not specifically ask about herbal supplements. It is important for emergency physicians to be aware of the potential for herbal supplements to contribute to acute liver injury and be able to investigate the active agents reported in these formulations. The diagnostic criteria for cholestatic jaundice and drug-induced liver injury are discussed.

Hypertensive Urgency: An Undesirable Complication of a "Male Performance" Herbal Product.

BACKGROUND: Hypertensive urgency is a clinical scenario that may be associated with herbal supplement use and that requires special consideration with regard to emergency department management. CASE REPORT: A 49-year-old man presented to the emergency department with palpitations and severely elevated blood pressure without evidence of end organ dysfunction. Hypertension failed to be controlled with multiple doses of oral clonidine and intravenous labetalol. The patient later admitted to using an herbal supplement containing yohimbine, a selective ⍺2-adrenoreceptor antagonist specifically linked to cases of refractory hypertension. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Between 17-35% of the U.S. adult population may use herbal supplements on a sporadic or regular basis; pharmacologically active agents in herbal supplements may affect both a patient's presentation and response to treatment. Most patients do not mention over-the-counter and herbal products in their medication profile unless specifically asked, and therefore it is important for emergency physicians to be aware of the pharmacologic effects of herbal supplements in the evaluation and treatment of refractory severe hypertension.