title: Herbal hepatotoxicity: suspected cases assessed for alternative causes.
abstract: OBJECTIVE
  Alternative explanations are common in suspected drug-induced liver injury (DILI) and account for up to 47.1% of analyzed cases. This raised the question of whether a similar frequency may prevail in cases of assumed herb-induced liver injury (HILI).
  
  
  METHODS
  We searched the Medline database for the following terms: herbs, herbal drugs, herbal dietary supplements, hepatotoxic herbs, herbal hepatotoxicity, and herb-induced liver injury. Additional terms specifically addressed single herbs and herbal products: black cohosh, Greater Celandine, green tea, Herbalife products, Hydroxycut, kava, and Pelargonium sidoides. We retrieved 23 published case series and regulatory assessments related to hepatotoxicity by herbs and herbal dietary supplements with alternative causes.
  
  
  RESULTS
  The 23 publications comprised 573 cases of initially suspected HILI; alternative causes were evident in 278/573 cases (48.5%). Among them were hepatitis by various viruses (9.7%), autoimmune diseases (10.4%), nonalcoholic and alcoholic liver diseases (5.4%), liver injury by comedication (DILI and other HILI) (43.9%), and liver involvement in infectious diseases (4.7%). Biliary and pancreatic diseases were frequent alternative diagnoses (11.5%), raising therapeutic problems if specific treatment is withheld; pre-existing liver diseases including cirrhosis (9.7%) were additional confounding variables. Other diagnoses were rare, but possibly relevant for the individual patient.
  
  
  CONCLUSIONS
  In 573 cases of initially assumed HILI, 48.5% showed alternative causes unrelated to the initially incriminated herb, herbal drug, or herbal dietary supplement, calling for thorough clinical evaluations and appropriate causality assessments in future cases of suspected HILI.
authors.affiliation: aDepartment of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Academic Teaching Hospital of the Medical Faculty bInstitute of Industrial, Environmental and Social Medicine, Medical Faculty, Goethe University, Frankfurt/Main cDepartment of Medicine I, University Medical Center, Hamburg-Eppendorf, Germany.
authors.forename: Rolf
authors.initials: R
authors.lastname: Teschke
authors.forename: Johannes
authors.initials: J
authors.lastname: Schulze
authors.forename: Alexander
authors.initials: A
authors.lastname: Schwarzenboeck
authors.forename: Axel
authors.initials: A
authors.lastname: Eickhoff
authors.forename: Christian
authors.initials: C
authors.lastname: Frenzel
mesh_terms: D056486:Chemical and Drug Induced Liver Injury / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology*; D003937:Diagnosis, Differential; D003951:Diagnostic Errors; D019587:Dietary Supplements / Q000009:adverse effects*; D006801:Humans; D028321:Plant Preparations / Q000009:adverse effects*; D011237:Predictive Value of Tests; D018570:Risk Assessment; D012307:Risk Factors
chemical_list: D028321:Plant Preparations