Table 4.

Typical follow-up of symptoms in a case of HILI by Indian Ayurvedic herbs.

Conditions	Symptoms
● Herbal use for overall 9 months, with full daily dose as recommended for the initial 7 months.	Well-being during first 6 months of treatment with Indian Ayurvedic herbs for her vitiligo. Pruritus as first symptom after herbal treatment for 6 months, with subsequent symptoms step by step: Loss of appetite, fatigue, nausea, and vomiting several times per week.
● After herbal use for 7 months, dose reduction to 50% for the remaining 2 months of treatment. Dose reduction was the patient’s decision. The clinic in India, which distributed this herbal medicine via internet, denied an association with the described symptoms.	Dark urine after use of herbs for 7 months. Reduced daily dose led to disappearance of pruritus but other symptoms persisted. Light-colored stool as new symptom appearing 8 months after initiation of the herbal treatment.
● First presentation to her PCP 9 months after initiation of herbal treatment	Jaundice was objectively confirmed
● Discontinuation of herbal treatment 9 months after treatment initiation and 3 months following emerging pruritus as the first symptom	Hospital admission the other day and discontinuation of the herbal treatment as HILI was suspected. Clinical evaluation with exclusion of alternative diagnoses including HEV. Causality assessment by RUCAM that provided a probable causality. Following cessation of herbal treatment, clinical symptoms and LTs rapidly improved to complete recovery. This case is best described as idiosyncratic HILI of the metabolic type.

Additional details are presented in a previous report [41]. Abbreviations: HEV, Hepatitis E Virus; HILI, Herb induced liver injury; PCP, Primary care provider; RUCAM, Roussel Uclaf Causality Assessment Method; LT, liver tests.