Controversy on a Newly Published Case of Assumed Acute Liver Failure One Day after Kava Use: Issues of Confounders, Causality, and an Undetermined Cause
DOI:
https://doi.org/10.12970/2308-8044.2020.08.04Keywords:
Herb induced liver injury, RUCAM, acute liver failure, multiorgan failure, hemorrhagic shock, shock liver, sepsis, kava, acetaminophen, amitriptyline, cannabis.Abstract
In a recent case report from the Michigan State University, acute liver failure (ALF) was diagnosed one day after the alleged use of an unspecified herbal product possibly containing kava (Piper methysticum Forst.). The available details are insufficient for a formal causality assessment and remind us of pitfalls often associated with the diagnosis of herb induced liver injury: incomplete collection of data relevant for the diagnosis, disputable interpretation of clinical features, and ignoring of variables that confound the diagnosis. Considering the published case, the diagnosis of ALF is likely not correct. It is not based on mainstream criteria and shows a long list of confounding variables: comedication with the potentially hepatotoxic amitriptyline and cannabinoids, hypovolemic shock secondary to massive retroperitoneal hemorrhage, shock liver, extensive mesenteric ischemia with pneumatosis throughout the bowel walls and the liver, sepsis with septic shock, and acute renal failure. Causality assessment was attempted in the published report using the Naranjo method, which is unsuitable for liver injury cases. The use of a robust diagnostic algorithm like RUCAM (Roussel Uclaf Causality Assessment Method) was missing. In essence, the disease is best classified as multiorgan failure of undetermined etiology rather than as ALF caused by kava.References
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