Danger of Herbal Tea: A Case of Acute Cholestatic Hepatitis Due to Artemisia annua Tea

Abstract

Background: Artemisia annua is a Chinese medicinal herb. Artemisinin-derivatives are recommended as part of a combination treatment for uncomplicated malaria. Herbal and dietary supplements (HDS) are increasingly used worldwide and HDS-induced liver injury is becoming a growing concern.Case Report: We present the first case of severe acute cholestatic hepatitis due to the intake of Artemisia annua tea as chemoprophylaxis for malaria in a patient returning from Ethiopia. The patients presented with jaundice, elevated transaminases, and parameters of cholestasis (total bilirubin 186.6 μmol/L, conjugated bilirubin 168.5 μmol/L). A liver biopsy showed a portal hepatitis with lymphocytic infiltration of the bile ducts and diffuse intra-canalicular and intra-cytoplasmic bilirubinostasis. The toxicologic analysis of the Artemisia tea revealed the ingredients arteannuin b, deoxyartemisin, campher, and scopoletin. There were no other identifiable etiologies of liver disease. The Roussel Uclaf Causality Assessment Method (RUCAM) score assessed a “probably” causal relationship. Sequencing of genes encoding for hepatic transporters for bile acid homeostasis (BSEP, MDR3, and FIC1) found no genetic variants typically associated with hereditary cholestasis syndromes. Normalization of bilirubin occurred 3 months after the onset of disease.Conclusion: The use of artemisinin-derivatives for malaria prevention is ineffective and potentially harmful and should thus be discouraged. Moreover, the case demonstrates our as yet inadequate understanding of the pathophysiology and susceptibility to HDS induced liver injury.

Artemisia annua Growing Wild in Romania—A Metabolite Profile Approach to Target a Drug Delivery System Based on Magnetite Nanoparticles

“…The mass spectra (Figure 2) showed the presence of complex metabolite composition. A total of 103 compounds were detected and identified, which covered various chemical categories, including amino acids, sterols, terpenoids, flavonoids, coumarins, alcohols, aldehydes, glycosides, carbohydrates, fatty acids and so on, which confirmed the data reported in the literature [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24]28,[31][32][33][34][35][36][37][38][39]46,[53][54][55][56][57][58][59][60]. Additionally, the presence of amino acids identified through GC-MS was confirmed via ESI-QTOF-MS The results are listed in Table 1, which presents tentative amino acid identification via GC-MS corresponding to Artemisia annua sample [32,54,55].…”

“…Recently, several cases of liver disease have been reported, especially following selfmedication with herbal supplements to manage cancer or prevent malaria [38,39].…”

Worldwide Use of RUCAM for Causality Assessment in 81,856 Idiosyncratic DILI and 14,029 HILI Cases Published 1993–Mid 2020: A Comprehensive Analysis

“…With 11,609 the largest HILI case number was published in 2019 ( Figure 3 ) as a consequence of the ongoing worldwide use of RUCAM for assessing causality in suspected HILI cases ( Table 4 ). In particular, contributing countries were in alphabetical order Australia [ 29 ], Brazil [ 183 ], China [ 48 , 196 , 197 , 198 , 199 , 200 , 201 ], Germany [ 213 , 214 , 215 ], India [ 217 ], Italy [ 222 ], Korea [ 103 ], Spain [ 115 , 117 , 240 , 241 , 242 ], Switzerland [ 244 ], and the US [ 245 , 246 , 247 , 248 , 249 , 250 , 251 , 252 , 253 , 254 ]. Most of the 11,619 HILI cases published in 2019 were from China [ 48 , 196 ] and Korea [ 103 ], with 6971 cases published by Shen et al [ 48 ], 2019 cases reported by Byeon et al [ 103 ], and 1552 cases provided by Chow et al [ 196 ].…”

Herb-induced hepatitis secondary to artemisinin: A case report

“…Lobular inflammation ( 5 ) and lymphocytic infiltration of the bile ducts ( 6 ) have been found on live biopsy.…”