|Ahead of print publication
A rare case of liver failure due to consumption of mahogany seeds
Prakash S Shende1, Pavan Nallamothu2
1 Department of Medicine, Dr. D. Y. Patil Hospital and Research Centre, Pune, Maharashtra, India
2 Department of General Medicine, Dr. D. Y. Patil Hospital and Research Centre, Pune, Maharashtra, India
|Date of Submission||19-Mar-2020|
|Date of Decision||16-Jun-2020|
|Date of Acceptance||24-Jul-2020|
Department of General Medicine, Dr. D. Y. Patil Hospital and Research Centre, Pimpri, Pune - 411 018, Maharashtra
Source of Support: None, Conflict of Interest: None
The use of complementary and alternative medical therapies is increasing worldwide. Many of these products have biological activity that can lead to severe toxicity or interact with prescribed medications. We present here a case of 68-year-old female, a known diabetic and hypertensive on treatment, who presented with symptoms of liver failure. This was associated with the consumption of mahogany seeds (sky fruit). She was investigated for other causes of liver failure, which turned out negative. It is important to recognize such possible complications during these therapies and promptly withdraw the offending agent.
Keywords: Drug-induced liver injury, liver failure, mahogany seeds
| Introduction|| |
Liver injury is a possible consequence of the ingestion of any xenobiotic, including industrial toxins, pharmacologic agents like acetaminophen, and complementary and alternative medications. Acute liver failure is the clinical syndrome of liver dysfunction, coagulopathy, and encephalopathy developing within 26 weeks of the onset of symptoms in patients without pre-existing liver disease., Drug-induced liver injury (DILI) is a common cause among patients presenting with acute liver failure. This includes prescription drugs such as acetaminophen and herbal or dietary supplements. Many herbal products and dietary supplements have biological activity that can lead to severe toxicity or that interact with each other or with prescription medications. Fewer than 40% of patients disclose to their clinicians that they are using these products., Swietenia macrophylla seeds, also known as sky fruits or Mahogany, have been used traditionally in various parts of Asia as a remedy for diabetes, hypertension, hyperlipidemia, and various ailments., There have been a few reports of hepatotoxicity due to the consumption of this product. The lack of randomized trails makes assessing the safety and efficacy of such remedies difficult. We present here, one such case.
| Case Report|| |
A 68-year-old female, homemaker by occupation was brought to outpatient department with complaints of vomiting, yellowish discoloration of eyes, urine and skin and generalized weakness, increased sleep for the past 15 days. She also complained of pain in the abdomen and burning micturition. The patient was a known case of diabetes mellitus for 9 years on tablet metformin 500 mg + glimipiride 2 mg + pioglitazone 15 mg taking twice daily, tablet linagliptin 5 mg once daily. She was also taking 12 IU of insulin glargine subcutaneous at night. She was a known hypertensive for 8 months and was taking tablet telmisartan 40 mg + metoprolol 25 mg once daily.
On examination, the patient had pallor and icterus and was vitally stable. Tenderness was present over the right hypochondrium. There was no shifting dullness or fluid thrill. The patient was semi-conscious but responsive to stimuli and obeying simple verbal commands.
The patient had initial investigations done from an outside lab, showing deranged liver function tests with markedly elevated Transaminases. Her serum total bilirubin was 7.3 mg/dL (direct: 3.83 mg/dL indirect: 3.47 mg/dL), serum glutamic pyruvic transaminase (SGPT) 1390 U/L, serum glutamic oxaloacetic transaminase (SGOT) 1835 U/L, and alkaline phosphatase (ALP) was normal. Complete blood count was suggestive of microcytic hypochromic anemia with hemoglobin of 9.9 g/dL. Urine analysis showed 70-80 pus cells/hpf. Viral serologies, including hepatitis A IgM antibodies, hepatitis B surface antigen, hepatitis C antibodies, hepatitis E IgM antibodies, were negative, ruling out viral hepatitis. Repeat liver function tests (LFTs) were sent and showed reduction in transaminases as compared to previous report, but hyperbilirubinemia persisted (total bilirubin: 8.37 mg/dL, direct: 6.12 mg/dL, indirect: 2.25 mg/dL; SGPT: 328 IU/L, SGOT: 335 IU/L ALP: 272 IU/L). Her prothrombin time was elevated with an INR of 1.92. Renal parameters were within the normal limits (serum creatinine: 1.3 mg/dl; blood urea: 32 mg/dL). An autoimmune hepatitis panel was negative for antinuclear antibodies, anti-smooth muscle antibodies, and anti-liver kidney microsomal type 1 antibodies. Serum ceruloplasmin and 24 h urinary copper levels were normal.
Ultrasonography of the abdomen and pelvis showed increased echogenicity of the liver with mild prominence of intrahepatic biliary radicles. Gall bladder wall and pericholecystic edema was found and there was minimal ascites. These findings together were consistent with that of hepatitis.
The patient was treated with intravenous Antibiotics, L-Ornithine L-Aspartate, Ursodeoxycholic acid, rifaximin, syp lactulose, insulin according to BSL. Over the course of hospital stay patients' consciousness level improved. She developed generalized body swelling, pitting pedal edema, ascites, which was progressively increasing in nature even after being put on injection furosemide and injection albumin, tablet spironolactone. On further inquiry, the patient revealed that she had been consuming Mahogany seeds (Sky fruit), about 3–4/day for the past 8 months. With this history, the patient was diagnosed with acute liver failure due to mahogany seeds consumption with hepatic encephalopathy with urinary tract infection in a known case of hypertension and diabetes mellitus.
Contrast-enhanced computed tomography (A + P) was done and was suggestive of - Liver parenchymal disease; prominent in calibre portal venous system without any apparent portosystemic collaterals; psuedowall thickening of gall bladder; diffuse wall thickening of the stomach, suggestive of gastritis; severe ascites with mesenteric congestion and bilateral mild pleural effusion; diffuse subcutaneous edema.
The patient was referred to a higher center in view of liver biopsy and the possible need for liver transplantation. On discharge, her total bilirubin was 8.11 mg/dL, direct bilirubin 5.14 mg/dL; SGPT 84 IU/L; SGOT 60 IU/L; ALP 211 IU/L; Blood Ammonia 72.9 mcg/dL.
On follow-up, patients LFTs have improved and normalized 6 weeks after discontinuing the consumption of seeds.
| Discussion|| |
The assessment and diagnosis of suspected cases of DILI involve the exclusion of other causes of liver injury, obtaining a thorough history, and the identification of symptoms that are related temporally to the exposure of suspected drug or toxin. The clinical presentations of injury secondary to herbal and dietary supplements are less typical and not been well-defined.
Mahogany seeds are also known as S. macrophylla seeds. The fruit of the mahogany seeds is commonly known as “Sky fruit.” Due to its perceived benefits, it is being used as part of traditional medication in Southeast Asia for various ailments. Mahogany seeds are used traditionally in Malaysia and other countries for the regulation of blood sugar and cardiovascular health.,
Laboratory studies on rats have found that Swietenia had significant hypoglycemic and hypolipidemic activity., However, there is a lack of efficacy and safety data on the use of mahogany seeds in humans. Hepatotoxicity due to the consumption of Mahogany seeds or its extract is rare, and only about 10 cases have been reported worldwide till date.,,, Between 2015 and 2018, health sciences Authority, Singapore, has received at least seven cases of liver injury of varying severity, ranging from mild liver function impairment to liver failure suspected to be associated with mahogany seeds. The pattern of liver toxicity was either hepatocellular or mixed (hepatocellular and cholestatic). Most of them were reported to have underlying medical conditions, including diabetes, hypertension, hyperlipidemia and were taking other medications concurrently.
DILI can be either direct (intrinsic) or idiosyncratic. Intrinsic DILI is predictable and dose-dependent. Idiosyncratic DILI is less common, affects only susceptible individuals, has a less consistent relationship to dose, and is more varied in its presentation. The idiosyncratic nature of Swietenia and other herbal and dietary supplements and lack of well-documented reports of such products make it a diagnostic challenge. Our patient had a hepatocellular pattern of liver injury. The diagnosis of acute liver failure due to mahogany seed consumption was made based on a combination of history and examination findings, appropriate use of investigations, ruling out other possible causes of liver injury, and normalization of liver function tests following the withdrawal of the seeds.
The mainstay of treatment includes the withdrawal of the offending toxin or drug, which was sky fruit in this case, supportive care, and monitoring till liver function tests normalize. With these measures, our patients LFTs normalized 6 weeks after stopping the consumption of the product.
| Conclusion|| |
Ascertaining that an episode of liver injury is caused by a drug, toxin, or an alternative medication is difficult in most cases. DILI requires careful history taking to identify unrecognized exposure to chemicals at work or home, drugs taken by prescription or bought over the counter, and herbal or dietary supplements. Hence, health-care professionals should give emphasis on patients' use of any herbal or complementary products as these may lead to serious complications if not recognized early and discontinued. Mahogany seeds or its extract can cause liver injury and prove to be fatal for the patient. Unregulated use of such products without adequate research, clinical trials, and safety monitoring should be discouraged.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bernal W, Wendon J. Acute liver failure. N Engl J Med 2013;369:2525-34.
Lee WM. Acute liver failure. Semin Respir Crit Care Med 2012;33:36-45.
Ostapowicz G, Fontana RJ, Schiødt FV, Larson A, Davern TJ, Han SH, et al
. Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Ann Intern Med 2002;137:947-54.
Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in use of complementary and alternative medicine by US adults: 1997-2002. Altern Ther Health Med 2005;11:42-9.
Eisenberg DM, Kessler RC, Van Rompay MI, Kaptchuk TJ, Wilkey SA, Appel S, et al
. Perceptions about complementary therapies relative to conventional therapies among adults who use both: results from a national survey. Ann Intern Med 2001;135:344-51.
Ch'ng YS, Loh YC, Tan CS, Ahmad M, Asmawi MZ, Wan Omar WM, et al
. Vasodilation and antihypertensive activities of Swietenia macrophylla
(Mahogany) seed extract. J Med Food 2018;21:289-301.
Dewanjee S, Maiti A, Das AK, Mandal SC, Dey SP. Swietenine: a potential oral hypoglycemic from Swietenia macrophylla
seed. Fitoterapia 2009;80:249-51.
Naveen YP, Divya Rupini G, Ahmed F, Urooj A. Pharmacological effects and active phytoconstituents of Swietenia mahagoni: a review. J Integr Med 2014;12:86-93.
Joanna, Yee Leong W, Wah Soe W, Vasudevan A, et al
. 42.Consumption of Swietenia macrophylla seeds can lead to hepatitis and autoimmune phenomena. Rheumatology Advances in Practice 2018 Sep;2(Suppl 1).
Yeap V, Tan TJY, Loh T, et al
. Liver failure associated with mahogany seed extract consumptionCase Reports 2018;2018:bcr-2018-225382.
Tan Y, Chen H, Zhou X, Sun L. RUCAM-based assessment of liver injury by xiang-tian-guo (Swietenia macrophylla
) seeds, a plant used for treatment of hypertension and diabetes. Ann Hepatol 2019;18:406-7.
Xia C, Liu Y, Yao H, Zhu W, Ding J, Jin J. Causality assessment of skyfruit-induced liver injury using the updated RUCAM: A case report and review of the literature. J Int Med Res 2020;48:300060520917569.
Andrade RJ, Chalasani N, Björnsson ES, Suzuki A, Kullak-Ublick GA, Watkins PB, et al
. Drug-induced liver injury. Nat Rev Dis Primers 2019;5:58:1-22.