TABLE 2.
Pertinent investigations of patients with ashwagandha-related liver injury
| Patient 1 | Patient 2 | Patient 3 | Patient 4 | Patient 5 | Patient 6 | Patient 7 | Patient 8 | |
|---|---|---|---|---|---|---|---|---|
| Hemoglobin (g/L) | 12.1 | 13.4 | 12.6 | 11.8 | 12 | 11.9 | 11 | 14.2 |
| Total leukocyte count (×109/L) | 8.5 | 4.6 | 5.5 | 8.9 | 11.2 | 31 | 7.6 | 24.3 |
| Platelet counts (×103 per μL) | 148 | 234 | 180 | 215 | 192 | 80 | 112 | 157 |
| Total bilirubin (mg/dL) | 10.4 | 2 | 3.6 | 21.3 | 16.1 | 11.4 | 24.3 | 31.5 |
| Direct bilirubin (mg/dL) | 3.3 | 1 | 1.8 | 16.9 | 11.5 | 3.4 | 19.8 | 25.3 |
| Aspartate aminotransferase (IU/L) | 107 | 598 | 647 | 64 | 235 | 47 | 100 | 270 |
| Alanine aminotransferase (IU/L) | 66 | 736 | 409 | 159 | 188 | 97 | 63 | 354 |
| Alkaline phosphatase (IU/L) | 105 | 241 | 199 | 354 | 893 | 59 | 128 | 209 |
| Gamma-glutamyl transpeptidase (IU/L) | 709 | 118 | 268 | 342 | 213 | 178 | 223 | |
| Serum albumin (mg/dL) | 2.9 | 4.9 | 3.2 | 4.1 | 4.2 | 1.8 | 3.6 | 3.4 |
| Serum globulin (mg/dL) | 4.3 | 2.6 | 3.7 | 2.2 | 2.8 | 5.4 | 2.6 | 3.7 |
| International normalized ratio | 2.93 | 1 | 1.3 | 2.2 | 1 | 6.1 | 1.5 | 2.2 |
| Serum total IgG (g/L) | 14.8 | 17.2 | 20.2 | 16.4 | 11.5 | 18.6 | 17.2 | 12.4 |
| Antinuclear antibody | Negative | Negative | Positive | Negative | Negative | Positive | Negative | Positive |
| Anti-smooth muscle antibody | Negative | Negative | Negative | Negative | Negative | Negative | Negative | Negative |
| Anti–liver-kidney-microsomal antibody | Negative | Negative | Negative | Negative | Negative | Negative | Negative | Negative |
| R-ratio | 1.3 | 5.6 | 5.3 | 1.3 | 0.6 | 4.9 | 1.5 | 5.1 |
| Type of liver injury | Cholestatic | Hepatocellular | Hepatocellular | Cholestatic | Cholestatic | Mixed | Cholestatic | Hepatocellular |
| RUCAM score | 8, probable | 6, probable | 8, probable | 7, probable | 5, possible | 5, possible | 8, probable | 7, probable |
| HILI severity | Severe | Mild | Moderate | Severe | Severe | Severe | Severe | Severe |
| Liver biopsy done | No | Yes | Yes | Yes | Yes | No | Yes | Yes |
| Type of liver biopsy | — | Percutaneous | Percutaneous | Transjugular | Percutaneous | — | Percutaneous | Transjugular |
| Liver biopsy findings | ||||||||
| Main site of inflammation | — | Periportal | Portal | Portal | Portal | — | Lobular | Portal |
| Predominant type of inflammation | — | Lymphocytes, eosinophils | Lymphocytes, eosinophils | Lymphocytes, eosinophils | No or minimal inflammation | — | No or minimal inflammation | Lymphocytes, eosinophils |
| Interface hepatitis, severity | — | Yes, mild | Yes, mild | No | No | — | No | No |
| Necrosis, type | — | Yes, spotty | Yes, bridging | No | No | — | Yes, confluent | Yes, confluent |
| Fibrosis, stage (Ishak) | Known case of cirrhosis | Stage 1 | Stage 2 | No | No | Known case of cirrhosis | Stage 2 | Stage 6 |
| Steatosis, severity | — | Yes, moderate | Yes, severe | Yes, mild | Yes, mild | — | No | No |
| Eosinophilic infiltration, severity | — | Yes, moderate | Yes, severe | Yes, mild | Yes, mild | — | Yes, minimal | Yes, moderate |
| Hepatocyte rosettes | — | No | Yes | No | No | — | No | No |
| Cholestasis, site, severity | — | No | Yes, cellular and canalicular, severe | Yes, cellular and canalicular, severe | Yes, cellular and canalicular, moderate | — | Yes, cellular and canalicular, moderate | Yes, cellular and canalicular, moderate |
Abbreviations: HILI, herb-induced liver injury; RUCAM, Roussel Uclaf Causality Assessment Method.