An herbal supplement containing artemisinin may have triggered hepatitis in a Seattle man who was given the supplement by a naturopathic provider for treatment of a parasitic infection.
According to the case study reported in the Aug. 14 issue of Morbidity and Mortality Weekly Report, a man with normal liver function experienced worsening abdominal pain and spikes in liver enzymes after taking a supplement containing 600 mg of artemisinin for 10 days.
Given as combination therapy, artemisinin is a World Health Organization approved first-line treatment for malaria, but the dose used by the Seattle man was substantially higher than that used to treat malaria, according to an editorial note that accompanied the case report.
The supplement, made from leaves of the sweet wormwood shrub, has long been a staple of Chinese herbal medicine.
In laboratory studies, the only reports of hepatoxicity occurred in guinea pigs given 16 mg/kg/day of the artemisinin derivative artesunate for seven days and rats exposed to artesunate at 4/mg/kg/day for five days.
"Healthcare providers should be aware that patients might be taking herbal supplements containing artemisinin and consider inquiring about their use in patients being evaluated for hepatitis without a clear etiology," the MMWR editors wrote.
The 52-year-old man sought treatment for "long-standing abdominal discomfort." The naturopathic provider said the man's stool samples showed "an unidentifiable protozoan" and recommended a six-week course of the supplement. The recommended dose was two 100-mg capsules of artemisinin three times a day, an amount equal to 7.5 mg/kg/day of artemisinin.
The routine dose for treatment of malaria is 4 mg/kg/day for three days.
After a week the man's abdominal pain worsened and he began producing dark urine. Three days later he stopped taking the supplement, and three days after that, on Aug. 18, 2008, he sought care from his primary care physician.
Laboratory findings revealed elevated liver enzymes (serum alanine aminotransferase of 898 IU/L, aspartate aminotransferase of 280 IU/L, bilirubin of 3.1 mg/L, and alkaline phophatase of 258 IU/L) -- values consistent with hepatitis. Lab tests done five months earlier had shown normal liver function.
The man was hospitalized for three days for monitoring and supportive care. Over the two weeks following discharge, his liver function returned to normal and symptoms improved by Sept. 4, 2008.