Liver Injury Induced by Peumus boldus with Fatal Outcome. Case Report

Introduction and Objectives

Peumus boldus is a plant native to South America traditionally used to treat gastrointestinal ailments. There are reports of hepatotoxicity from prolonged consumption. We describe the case of a patient with liver damage induced by Peumus boldus, with a torpid evolution and fatal outcome, highlighting the awareness of the adverse effects of this plant.

Materials and Patients

A 48-year-old woman with a history of type 2 diabetes on insulin glargine treatment and a surgical history of cholecystectomy 12 years prior for cholelithiasis, without other relevant history. She began three weeks prior with asthenia, adynamia, hyporexia, nausea, fever, jaundice, and right hypochondrial pain. Upon questioning, exposure to an herbal supplement based on Peumus boldus during the previous 15 days was related. Upon admission with vital signs BP: 101/82 mmHg, HR: 98 bpm, RR: 21 rpm, Temperature: 38.2°C, SaO2 90%. On physical examination, generalized jaundice, dark urine, and pale stools were noted. Laboratories showed a cholestasis clinical pattern (R Factor of 1.0, with ALT of 62 U/L, ALP of 184 U/L). Despite discontinuing the herbal supplement, she progressed with progressive cholestasis on follow-up, leading to the initiation of glucocorticoids without improvement. Complementary studies were conducted, ruling out infectious and autoimmune diseases, as well as a transjugular liver biopsy reporting non-alcoholic steatohepatitis with morphological data of toxic-induced lesions with moderate activity.

Results

During her clinical course, with persistence of generalized jaundice and right hypochondrial abdominal pain, grade 2 ascites, and encephalopathy characterized by disorientation in time and circumstance, behavioral alterations, and eventually somnolence tendency, for which she was brought by family members to the emergency service of our hospital. During her hospital stay, she showed a tendency to hypotension, without adequate response to vasopressor treatment, with clinical and laboratory evidence of renal function deterioration, and worsening liver function parameters with BT of 22.1 mg/dl, DB 20.5 mg/dl, IB 1.6 mg/dl, ALT 64 U/L, ALP 188 U/L, Platelets 59,000 cells/mm3, PT 27.5 seconds, and INR 2.54. After 65 days from the onset of symptoms, despite the treatment used, a fatal outcome occurred.

Conclusions

Despite a growing number of reports of hepatotoxicity induced by Peumus boldus, it is not listed in databases intended for such purposes as LiverTox. This case highlights the importance of raising awareness about the hepatotoxic risks of herbal products.

Ethical Statement: This clinical case was prepared following current ethical standards and principles in medical research. Informed consent was obtained from the patient's legal representative for the anonymous publication of her clinical data. Confidentiality and respect for the patient's privacy were always guaranteed, according to the provisions established in the Declaration of Helsinki and the guidelines of the Ethics Committee of the General Hospital ISSSTE, Querétaro. No experimental interventions were performed, and all therapeutic measures applied were part of the standard of medical care.

Declaration of Interests: None.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.