Acute liver failure temporally associated with intensive consumption of Plantago major tea: A case report

Table 1 Clinical timeline of the case

Period/date	Clinical event
Approximately 2 months before hospitalization	Epigastric pain developed. Upper gastrointestinal endoscopy showed moderate erosive gastritis, and omeprazole was initiated; the exact dose and treatment dates were unavailable
Subsequent 15 days	Because abdominal pain did not improve, the patient self-administered approximately 2 L/day of a prepared P. major infusion. The preparation was not botanically authenticated or chemically analyzed
After herbal exposure	Abdominal pain worsened, followed by jaundice, dark urine, and acholic stools
June 17-20, 2024	Enteral N-acetylcysteine was administered using a 72-hour regimen consisting of a 140 mg/kg loading dose followed by 70 mg/kg every 4 hours for 17 maintenance doses
June 21-July 1, 2024	Prednisolone 40 mg/day was administered; the clinical course nevertheless progressed
July 2, 2024	The first complete laboratory panel available for retrospective review showed severe liver injury and dysfunction. INR reached 2.27, serum ammonia was 146 μmol/L, and hepatic encephalopathy progressed to West Haven grade III
July 3, 2024	Non-contrast head CT showed no significant acute intracranial abnormality, including no acute hemorrhage, mass lesion, midline shift, or herniation
July 4, 2024	Urgent orthotopic liver transplantation was performed because of rapidly progressive acute liver failure with grade III hepatic encephalopathy and worsening hepatic dysfunction
July-August 2024	Initial graft recovery was documented by rapid normalization of INR, progressive reductions in bilirubin and aminotransferases, and preserved renal function. Early post-transplant CMV DNAemia subsequently became undetectable
March 20, 2025	Liver biopsy demonstrated acute cellular rejection, Banff Rejection Activity Index 5
March 25-27, 2025	First course of high-dose intravenous methylprednisolone (1 g/day for 3 days), with partial biochemical improvement
April 7, 2025	Repeat liver biopsy demonstrated persistent/recurrent acute cellular rejection, Banff Rejection Activity Index 6
April 11-13, 2025	Second course of high-dose intravenous methylprednisolone (1 g/day for 3 days); graft dysfunction and marked cholestasis persisted
May 15, 2025	A third liver biopsy again demonstrated acute cellular rejection, Banff Rejection Activity Index 6. Complementary C4d immunohistochemistry showed no vascular endothelial staining, arguing against chronic rejection
May 30-June 6, 2025	Thymoglobulin was administered for steroid-refractory rejection
June-July 2025	The period of intensified immunosuppression was complicated by CMV DNAemia (176 IU/mL on June 3, 2025 and 15338 IU/mL on June 17, 2025), which was undetectable by July 29, 2025. Liver biochemical tests subsequently improved
September 1, 2026	At the most recent follow-up, the patient was alive with preserved graft synthetic and renal function: AST 31 U/L, ALT 35 U/L, ALP 95 U/L, GGT 88 U/L, total bilirubin 0.39 mg/dL, albumin 4.5 g/dL, INR 1.08, and creatinine 0.72 mg/dL

ALF: Acute liver failure; CT: Computed tomography; CMV: Cytomegalovirus; INR: International normalized ratio; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; ALP: Alkaline phosphatase; GGT: γ-glutamyl transferase; P. major: Plantago major.