A Disconcerting Death Secondary to Acute Drug-Induced Liver Failure and Refusal of Liver Transplant

Complementary and alternative medicines (CAMs) are being used at increasing rates within the U.S. population. Though readily available, these products are possible precipitants of acute liver failure (ALF). This is a case of acute liver failure in a patient taking herbal supplements. Case Report: A 41 year-old female vegan with a history of iron deficiency anemia presented with subacute yellowing of the eyes, nausea, and confusion. The patient took 27 herbal supplements, including Chaparral and Valerian, known precipitants of ALF. Initial labs included Alb 1.8, T Bili 17.1, INR 7.2, Alkaline Phosphatase 177, AST 444, ALT 250, and NH4 119. Consistent with history, toxicology screen was negative for serum acetaminophen, ethanol, and salicylates. Doppler ultrasound revealed patent hepatic vessels. Patient was transferred to a tertiary care center for evaluation for liver transplant. Evaluation for alternative causes was not suggestive of autoimmune or infectious etiologies. Patient and family expressed that medications were “chemicals” and they requested holistic interventions only. Psychiatric evaluation confirmed patient had capacity. Family supported patient's refusal of liver transplant. Integrative Medicine consultation was sought, however, therapeutic contribution was limited. Patient and family preemptively refused the use of immunosuppressive medications post-liver transplant. After multiple discussions regarding the severity of her acute illness, and limitations of alternative treatment options, patient declined being listed for liver transplant. Four days after initial presentation, patient and husband declined hospice referral and was discharged home at her request. Patient re-presented to the OSH two days after discharge with progression of encephalopathy. Although patient required ICU monitoring and intubation, family declined liver transplant evaluation, and 14 days after initial presentation, the patient expired. CAMs have become a significant cause of acute liver failure. Respecting a patient's belief structure is an important part of the practice of medicine. In this case, the patient's belief in herbal supplements precipitated acute liver failure and the patient's belief against western medicines created barriers to the recommended therapy. This combination directly contributed to the patents death. Given the increased utilization of CAM this may represent an increasingly common clinical challenge.