Liver Injury with Features Mimicking Autoimmune Hepatitis following the Use of Black Cohosh

Table 6

Similarities and differences among current case studies and published cases of black cohosh hepatotoxicity.

Case reports	Whiting Case $1^{*}$	Whiting Case $2^{*}$	${\text{Lontos}}^{*}$	${\text{Levitsky}}^{*}$	${\text{Cohen}}^{*}$	${\text{Lynch}}^{*}$	Chow	Nisbet	Current study Case $1^{\#\#}\mathrm{\hspace{0.17em}\hspace{0.17em}}$	Current study Case $2$
Age/gender	47F	43F	52F	50F	57F	54F	51F	50F	42F	53F
Botanical dietary contents	Black cohosh	Black cohosh, skullcap#, Valerean, Passionflower	Black cohosh, ground ivy#, golden seal, Gingko, oat seed	Black cohosh	Black cohosh	Black cohosh	Black cohosh	Black cohosh	Black cohosh	Black cohosh, soy
Other drugs					Levothyroxine	Levothyroxine			Levothyroxine	Dicyclomine
Serologies indicating presence of other liver diseases				Absent		Absent	Absent		Absent	Absent
Lab data indicating presence of other liver diseases				Absent		Absent	Absent		Absent	Absent
Presenting symptom	Jaundice		ALF	ALF		ALF	Jaundice	Acute hepatitis	Acute hepatitis	RUQ pain
Main liver biopsy finding				Acute hepatitis		Acute hepatitis	Massive liver necrosis		Centrilobular necrosis	Centrilobular necrosis
Lobular infiltrate						Mixed $+$ plasma cells	Mononuclear infiltrate		Plasma cytic infiltrate	Lymphop-lasmacytic infiltrate
Other lobular findings				Necrosis		Bridging necrosis	Preserved bile ducts, collapsed parenchyma		Lobular disarray	Lobular disarray
Therapy				Prednisone	Immuno-therapy	Prednisone			Prednisone & azathioprine	Prednisone
Intervention	OLT			OLT		OLT	OLT	Withdrawal of black cohosh	Withdrawal of black cohosh	Withdrawal of black cohosh
Outcome		Recovery	LF s/p d/c black cohosh	Recovery	Recovery	LF death hemorrhage	Recovery	Recovery	Recovery	Recovery
AIH like histology					Present	Present	Present		Present	Present
Serological marker for AIH				Absent	Absent	Absent	Absent		Absent	Absent
Issues disputing validity of black cohosh hepatoxicity	Drug use for only 6 days	Multi-drug product	Multi-drug product	Multi drug use Ethanol, NSAID & cyclovir	7 day use; maybe AIH			2 weeks exposure; cholelithiasis	Maybe AIH

${}^{*}$Cases adapted from Table 1 Lynch [5]; ALF: Acute liver failure; RUQ: Right upper quadrant pain.
OLT: Orthotopic liver transplant; LF: Liver failure.
${}^{\#}$Herbal remedies known as hepatotoxic; ${}^{\#\#}$Also reported by Mahady [9]; AIH: Autoimmune hepatitis.