Which teabag would you prefer?
Drinking green tea is supposed to be good for you as it is helpful in treating or preventing:
• rheumatoid arthritis
• high cholesterol levels
• cardiovascular disease
• impaired immune function, etc.
More recent evidences suggest that green tea can even help people who are dieting as it helps to burn calories.
However, drinking too much of the green stuff is not a good idea if you're not sure what exactly is in the teabag.
A 17 y/o female student, morbidly obese showed the following symptoms:
• weakness since 2 weeks
• jaundice (yellowing of the eyes and skin) since 5 days
• dark urine since 5 days
• nausea since 2 days.
She denied abdominal pain, changes in her stool, fever, joint pain, changes in mental status, alcohol consumption, any recent drug consumption (eg. Paracetamol etc.), sick contacts or recent travel.
She has a H/O obesity and had been doing strenous exercise (approximately 2 hours per day), along with consumption of about four cups of green tea per day for a little over two months.
Over this time period, she lost 10 kgs.
Family H/O obesity: present.
No other significant medical or surgical history.
On P/E: the patient was jaundiced, most evident in the face and sclera, but also present on the chest and upper extremities. Mental status was intact.
Abdominal exam: was insignificant, with the liver difficult to appreciate given that the patient was still overweight at the time of exam.
Initial labs included:
• aspartate aminotransferase (AST): 1982 U/L (normal range 15-40 U/L)
• alanine aminotransferase (ALT): 2436 U/L (normal range 10-45 U/L)
• alkaline phosphatase: 168 U/L (normal range 116-483 U/L)
• gamma glutamyl transferase (GGT): 72 U/L (normal range 12-33 U/L)
• conjugated bilirubin (CB): 12.9 mg/dL (normal range < 0.3 mg/dL)
• unconjugated bilirubin (UB): 1.9 mg/dL (normal range < 0.1 mg/dL)
• albumin: 4.2 g/dL (normal range 3.7-5.5 g/dL)
• partial thromboplastin time: 32.9 s (normal range 25.4-34.9 s)
• protime: 15.7 s (normal range 11.2-15.4 s)
• international normalised ratio (INR): 1.3 (normal range 0.8-1.2)
• random glucose: 99 (normal range: <200mg/dl)
She was admitted for work-up of acute liver injury and possible impending liver failure.
During her hospitalization her peak INR and CB were 1.5 and 17.5 mg/dL, respectively. Her lowest albumin and factor 7 level was 2.5 g/dL and 39% (normal range 58%-150%), respectively, indicating a decline in liver function.
Radiological exam: was done on admission and consisted of an abdominal ultrasound with Doppler, which read as mild hepatomegaly with normal right upper quadrant Doppler evaluation.
• Extensive lab work was ordered.
• Serological markers of autoimmune hepatitis, infectious hepatitis, and alpha-1-antitrypsin (A1AT) deficiency were negative.
• In addition, cytomegalovirus (CMV) and Epstein-Barr virus (EBV) immunoglobulin M/immunoglobulin G and adenovirus polymerase chain reaction (PCR) were negative.
• The patient had an ultrasound-guided liver biopsy completed on hospital day 5.
- Liver histology was notable for diffuse portal and lobular mixed inflammatory cell infiltrates with acute inflammation that included scattered eosinophils and interface hepatitis.
- There was hepatocyte unrest and ballooning degeneration with multifocal individual hepatocyte necrosis and cholestasis. Injury was most prominent in zone 1.
She was observed and treated in the hospital until her liver panel began to improve.
She was seen again for follow up at various intervals at which time labs were repeated. All values continued to improve, along with normalization of both albumin and factor 7 levels, indicating resolution and recovery of her liver function.
As several causes of acute liver injury were ruled out, and given her liver histology consistent with previously published reports of toxicity associated with green tea extract, along with the fact that the patient had ordered the suspected green tea online (after hearing claims from a friend that it could help her lose weight; all the ingredients were in Chinese, so neither she nor the doctors were sure exactly what was in the alleged "weight loss" green tea, and whether there were any harmful additions to the herbal beverage) her liver injury was most likely attributed to her ingestion of this commercially available green tea.
It was also observed that while admitted, the girl had stopped consuming it, and her symptoms improved rather quickly.
If you were in the treating doctor's position, what would your approach to treatment be for this case?