Session: SUN 723-739-Lipids: Therapeutics & Case Reports
Poster Board SUN-730
Authors: Christine C. Zacharia, MD1 and Hilary B. Whitlatch MD2
1Clinical fellow, 2Assistant Professor of Medicine, Department of Endocrinology, Alpert Medical School of Brown University, Providence, RI
Introduction: Severe cholestasis is associated with changes in lipid metabolism, including increased lipoprotein X, lecithin- cholesterol acyltransferase deficiency and hepatic triglyceride lipase deficiency. This results in reduced chylomicron uptake, increased LDL production, reduced serum HDL, and increased serum triglycerides. Rooibos (Aspalathus linearis) tea is consumed in the South African region for its flavor and potential antioxidant effects. While it has been linked to rare cases of hepatocellular injury, there have been no documented cases of mixed hepatocellular and cholestatic injury associated with severe lipid abnormalities.
Clinical Case: A 52 year old South African male with a history of IgA nephropathy and hyperlipidemia well-controlled on atorvastatin 10 mg daily [total cholesterol 141 (110 -199 mg/dL), triglycerides 109 (40 -150 mg/dL), HDL 33 (40-70 mg/dL)and LDL 86 (70-129 mg/dL)] presented with pruritis, jaundice and malaise. Liver function tests suggested mixed cholestasis and acute liver injury: AST 1438 (10-42 IU/L), ALT 2859 (6-45 IU/L), ALP 359 (40-130 IU/L), total bilirubin 12.1 (0.2-1.3 mg/dL), direct bilirubin 8.3 (0.0 – 0.3 mg/dL). Coagulation parameters were normal. His statin was held, and he was referred to the emergency department. An extensive infectious and autoimmune workup was unremarkable, as was a right upper quadrant ultrasound. On further questioning, he reported consuming increased quantities of rooibos tea over the prior 3 months. He underwent a liver biopsy, which demonstrated toxin-mediated liver injury. The liver service attributed this to roobois-mediated toxicity rather than statin-induced liver injury given the acute profound liver enzyme elevation in the setting of chronic atorvastatin use. His liver enzymes trended down, and he was discharged on ursodiol 300 mg BID.
He returned 5 days later with continued malaise. His sodium was 120 (135-145 mEq/L). As part of a hyponatremia evaluation, a lipid profile was obtained: total cholesterol 1262, triglycerides 408 and HDL <10. Cholestyramine 4 g po BID was initiated and he was discharged 1 week later.
Three weeks following discharge, his liver and lipid profiles were markedly improved: AST 30, ALT 53, total bilirubin 1.5, direct bilirubin 0.5, total cholesterol 342, triglycerides 136, HDL 104 and LDL 211.
Conclusion: Rooibos tea can induce mixed hepatocellular injury and cholestasis resulting in marked hypercholesterolemia.
Disclosure: HW: Coinvestigator, Takeda. Nothing to Disclose: CCZ
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