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Immune-mediated herb-induced liver injury: a potential association with herbal artemisinin use as supported by the updated RUCAM
  1. Akash Mathavan1,
  2. Akshay Mathavan1,
  3. Urszula Krekora2 and
  4. Karen Daily3
  1. 1College of Medicine, University of Florida, Gainesville, Florida, USA
  2. 2College of Medicine, University of Central Florida, Orlando, Florida, USA
  3. 3Hematology and Oncology, University of Florida, Gainesville, Florida, USA
  1. Correspondence to Akash Mathavan; amathavan2496{at}


Immune-mediated herb-induced liver injury (HILI) is an acute or chronic inflammatory liver disease precipitated by a hepatotoxic agent with a presentation similar to acute autoimmune hepatitis. It is distinguished in clinical course from true autoimmune hepatitis by remission on drug discontinuation and immunosuppressive treatment. We report a potential case of immune-mediated HILI associated with artemisinin use, an herb underlying first-line malarial treatments, in a woman undergoing radiotherapy for right-sided pelvic sarcoma. A probable association in this case is supported by causality assessment using the updated Roussel Uclaf Causality Assessment Method (score of 6). She achieved clinical improvement with a course of oral corticosteroids and remained stable without relapse following discontinuation. Increased awareness of this complication is imperative, as literature to date only documents direct hepatocellular and cholestatic liver injury from artemisinin use, and should augment clinician counsel regarding complementary medicine administration, especially in high-risk individuals like those with cancer.

  • Liver disease
  • Immunology
  • Vitamins and supplements
  • Unwanted effects / adverse reactions

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  • Contributors Akash Mathavan conceived of the idea for the case report and was primarily responsible for writing the manuscript. Akshay Mathavan helped with background research and assisted with writing the manuscript. UK contributed to background research and manuscript drafting. KD assisted with writing the manuscript, provided subject matter expertise and is responsible for its final content. Overall, the following authors were responsible for drafting of the text, sourcing and editing of clinical images, investigation results, drawing original diagrams and algorithms, and critical revision for important intellectual content: Akash Mathavan, Akshay Mathavan, UK and KD. All authors give final approval for the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.