Herb induced liver injury presumably caused by black cohosh: A survey of initially purported cases and herbal quality specifications

There are a growing number of cases detailing acute hepatic necrosis in patients taking black cohosh (Cimicifuga racemosa), an over-the-counter herbal supplement for management of menopausal symptoms. Our aim is to illustrate two cases of liver injury following the use of black cohosh characterized by histopathological features mimicking autoimmune hepatitis. Both patients reported black cohosh use for at least six months and had no evidence of another cause of liver disease. Their liver biopsies showed a component of centrilobular necrosis consistent with severe drug-induced liver injury. In addition, the biopsies showed characteristics of autoimmune-like liver injury with an interface hepatitis dominated by plasma cells. Although serum markers for autoimmune hepatitis were not particularly elevated, both patients responded to corticosteroids, supporting an immune-mediated component to the liver injury. Liver injury following the use of black cohosh should be included in the list of differential diagnoses for chronic hepatitis with features mimicking autoimmune hepatitis.

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Case of cholestatic drug-induced liver injury (DILI) associated with black cohosh

BMJ Case Reports ◽

10.1136/bcr-2020-240408 ◽

2021 ◽

Vol 14 (5) ◽

pp. e240408

Author(s):

Himmat Singh Brar ◽

Rachana Marathi

Keyword(s):

Liver Injury ◽

Liver Enzymes ◽

American Woman ◽

Black Cohosh ◽

Herbal Supplement ◽

Drug Induced ◽

Drug Induced Liver Injury ◽

Postmenopausal Symptoms ◽

Autoimmune Pathology ◽

History Of

Drug-induced liver injury is an uncommon yet fatal cause of liver injury. Black cohosh is a herbal supplement that is derived from Actaea racemosa. It has been used for vasomotor symptoms in postmenopausal women, but it can cause liver injury. A 50-year-old Afro-American woman presented with a 2-month history of malaise, itching and severe jaundice. The labs showed elevation of bilirubin and alkaline phosphatase. The patient had a history of black cohosh use for postmenopausal symptoms before she developed her current symptoms. The extensive workup for infective and autoimmune pathology was negative. Black cohosh was discontinued. The patient improved clinically, and her liver enzymes normalised 6 months after the discontinuation of black cohosh. This report emphasises the need to recognise black cohosh as a potential hepatotoxic agent and to monitor the liver enzymes for a patient on black cohosh.

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Charms & Harms: Black cohosh

Journal of Primary Health Care ◽

10.1071/hc10079 ◽

2010 ◽

Vol 2 (1) ◽

pp. 79 ◽

Cited By ~ 1

Author(s):

Joanne Barnes

Keyword(s):

Liver Injury ◽

Liver Function ◽

Health Professionals ◽

Herbal Medicines ◽

Signs And Symptoms ◽

Black Cohosh ◽

Efficacy And Safety ◽

Drug Reactions ◽

Function Test ◽

Suspected Adverse Drug Reactions

SUMMARY MESSAGE: Evidence for the efficacy of black cohosh extracts for treatment of menopausal symptoms is inconclusive. Black cohosh extracts have been associated with hepatotoxic reactions including changes in liver function test values, hepatitis, jaundice and hepatic failure. Health professionals should be aware of the possibility of (undisclosed) use of black cohosh, particularly among patients of menopausal age, be vigilant to signs of liver injury in patients using black cohosh, inform users of black cohosh about the possibility of hepatotoxic reactions and signs and symptoms of liver injury. Suspected adverse drug reactions should be reported to CARM. As with all herbal medicines, different black cohosh products vary in their pharmaceutical quality, and the implications of this for efficacy and safety should be considered.

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A Delayed Case of Black Cohosh Associated Drug-Induced Liver Injury

Journal of Medical Cases ◽

10.14740/jmc3108w ◽

2018 ◽

Vol 9 (9) ◽

pp. 287-288

Author(s):

Sara Khodor ◽

Max Feldman

Keyword(s):

Liver Injury ◽

Black Cohosh ◽

Drug Induced ◽

Drug Induced Liver Injury

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Black Cohosh and Liver Toxicity: Is There a Relationship?

Case Reports in Gastrointestinal Medicine ◽

10.1155/2014/860614 ◽

2014 ◽

Vol 2014 ◽

pp. 1-3 ◽

Cited By ~ 5

Author(s):

Mohammed Muqeet Adnan ◽

Muhammad Khan ◽

Syed Hashmi ◽

Muhammad Hamza ◽

Sufyan AbdulMujeeb ◽

...

Keyword(s):

Liver Injury ◽

Liver Toxicity ◽

Weak Link ◽

Hot Flashes ◽

The United States ◽

Black Cohosh ◽

Drug Side Effects ◽

Herbal Supplements ◽

Meta Analyses ◽

States Pharmacopeia

Herbal supplements are commonly used by patients for various problems. It is a well-known fact that most patients do not tell their physicians about the use of herbal supplements unless they are specifically asked. As a result, sometimes important information regarding drug side effects is missed in history taking. During our literature search, we found several retrospective studies and other meta-analyses that claim a lacking or weak link between black cohosh use and hepatotoxicity. We present a case of a 44-year-old female who developed subacute liver injury demonstrated on a CT scan and liver biopsy within a month of using the drug to resolve her hot flashes and discuss a possible temporal and causal association between black cohosh use and liver disease. Since the patient was not taking any other drugs, we concluded that the acute liver injury was caused by the use of black cohosh. We agree with the United States Pharmacopeia recommendations that a cautionary warning about hepatotoxicity should be labeled on the drug package.

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Effects of Steroids on Fetal Rat Liver

Proceedings, annual meeting, Electron Microscopy Society of America ◽

10.1017/s0424820100063664 ◽

1969 ◽

Vol 27 ◽

pp. 350-351

Author(s):

F. G. Zaki

Keyword(s):

Liver Injury ◽

Rat Liver ◽

Fetal Liver ◽

Dosage Level ◽

Maternal Plasma ◽

Methyl Prednisolone ◽

Fetal Rat ◽

Toxic Agents ◽

Fetal Rat Liver ◽

Neonatal Liver

Fetal and neonatal liver injury induced by agents circulating in maternal plasma, even though well recognized, its morphological manifestations are not yet established. As part of our studies of fetal and neonatal liver injury induced by maternal nutritional disorders, metabolic impairment and toxic agents, the effects of two anti-inflammatory steroids have been recently inves tigated.Triamcinolone and methyl prednisolone were injected each in a group of rats during pregnancy at a-dosage level of 2 mgm three times a week. Fetal liver was studied at 18 days of gestation. Litter size and weight markedly decreased than those of control rats. Stillbirths and resorption were of higher incidence in the triamcinolone group than in those given the prednisolone.

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