Danger of Herbal Tea: A Case of Acute Cholestatic Hepatitis Due to <em>Artemisia annua</em> Tea

Francisco Ruperti-Repilado

Simon Haefliger

Sophia Rehm

Markus Zweier

Anne Leuppi-Taegtmeyer+2 authors

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

^{University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland}

^{Institute of Pathology, University Hospital Basel, Basel, Switzerland}

^{Department of Laboratory Medicine, University Hospital Basel, Basel, Switzerland}

^{Institute of Medical Genetics, University of Zurich, Zurich, Switzerland}

^{Swiss Tropical and Public Health Institute, Basel, Switzerland}

^{Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Zurich, Switzerland}

^{Division of Clinical Pharmacology and Toxicology, Department of Medicine, University Hospital Basel, Basel, Switzerland}

Edited by: Pedro M. Baptista, Aragon Institute for Health Research (IIS Aragon), Spain

Reviewed by: Dipen Vyas, Biorg Inc., United States; Jia-bo Wang, Fifth Medical Center of the PLA General Hospital, China

*Correspondence: Christine Bernsmeier hc.sabinu@reiemsnreb.c

This article was submitted to Gastroenterology, a section of the journal Frontiers in Medicine

Edited by: Pedro M. Baptista, Aragon Institute for Health Research (IIS Aragon), Spain

Reviewed by: Dipen Vyas, Biorg Inc., United States; Jia-bo Wang, Fifth Medical Center of the PLA General Hospital, China

Received 2019 Jun 14; Accepted 2019 Sep 26.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

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.

Keywords: acute, cholestatic liver disease, drug induced liver injury, Artemisia annua tea, artemisinin, herbal and dietary supplement, malaria

Abstract

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