A Case of Sub Acute Liver Failure Associated with Black Cohosh Use - Abstract
Black cohosh is an herbal medication used for the treatment of postmenopausal
vasomotor symptoms. We report a case of sub acute liver failure associated with
black cohosh use. A 50 year-old female with hypertension, uterine fibroids, and recent
hospitalization for acute hepatitis secondary to black cohosh was readmitted with
asterixis and confusion. Two months prior, she started black cohosh and developed
scleral icterus, abdominal pain, nausea, and vomiting. She had no underlying liver
disease. Medications included hydrochlorothiazide and metoprolol. Family history
was significant for autoimmune hepatitis. She had a 4 pack-year smoking history and
endorsed having one drink daily for 10 years, but quit two months ago. Physical exam
on initial presentation was remarkable for jaundice. Her liver function tests (LFTs) were
abnormal, but no coagulopathy. Hepatitis panel and autoimmune serologies were
normal. RUQ ultrasound suggested hepatic steatosis. Liver biopsy revealed severe
acute hepatitis with sub massive hepatic necrosis. The patient was discharged with
improved LFTs on prednisone. One month later, the patient presented with asterixis
and confusion. Lab studies revealed abnormal LFTs, elevated serum ammonia, and
coagulopathy. A diagnosis of sub acute liver failure was made. The patient did not
require a transplant and recovered with conservative management. The patient scored
5 on the Roussel UCLAF causality assessment method, suggesting black cohosh as a
probable cause of her liver injury. In conclusion, we present a case of black cohosh
associated sub acute liver failure which developed weeks after the initial insult. This
case underscores the importance of close follow-up after the initial insult.