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

Abstract

BACKGROUND

Herb-induced liver injury is an increasingly recognized cause of acute liver injury, but severe hepatotoxicity associated with Plantago major (P. major) has not been well characterized in humans. We report a case of acute liver failure temporally associated with intensive consumption of P. major tea requiring urgent liver transplantation.

CASE SUMMARY

A previously healthy 44-year-old woman developed worsening abdominal pain, jaundice, dark urine, and acholic stools after consuming approximately 2 L/day of prepared P. major tea for 15 consecutive days. Her clinical condition rapidly progressed to grade III hepatic encephalopathy. At the first complete laboratory assessment available for retrospective review, alanine aminotransferase was 338 U/L, aspartate aminotransferase was 370 U/L, alkaline phosphatase was 194 U/L, and total bilirubin was 14.41 mg/dL, corresponding to an R factor of 6.27 and a hepatocellular pattern of injury. The international normalized ratio reached 2.27, serum ammonia was 146 μmol/L, and arterial lactate reached 4.52 mmol/L, while renal function remained preserved. The contemporaneous medical record documented negative investigations for viral hepatitis and autoimmune liver disease and documented that Wilson disease and hemochromatosis had been investigated and excluded. She received enteral N-acetylcysteine and corticosteroid therapy without reversal of the progressive clinical course. Given the rapidly progressive acute liver failure with grade III hepatic encephalopathy and worsening hepatic dysfunction, urgent liver transplantation was performed on July 4, 2024. Histopathological examination of the explanted liver demonstrated massive hepatic necrosis, marked cholestasis, and regenerative changes without fibrosis or steatosis; these findings were nonspecific and did not establish the etiology of the liver injury. The post-transplant course was subsequently complicated by persistent/recurrent biopsy-proven acute cellular rejection requiring corticosteroid pulses and thymoglobulin. At more than two years of follow-up, the patient remained alive with preserved graft synthetic and renal function.

CONCLUSION

This case describes severe acute liver failure temporally associated with intensive P. major tea consumption. Although the medical record documented negative investigations for viral hepatitis and autoimmune liver disease and exclusion of Wilson disease and hemochromatosis during the etiologic investigation, a definitive causal relationship with P. major cannot be established because the herbal preparation was not botanically authenticated or chemically analyzed and a complete structured causality assessment was not possible. Clinicians should systematically investigate herbal-product exposure in patients with otherwise unexplained acute liver injury.

Keywords: Plantago major; Herb-induced liver injury; Acute liver failure; Liver transplantation; Case report

Core Tip: This case describes acute liver failure temporally associated with intensive consumption of Plantago major tea in a previously healthy 44-year-old woman. After consuming approximately 2 L/day of prepared infusion for 15 consecutive days, she developed progressive hepatic dysfunction and grade III hepatic encephalopathy, ultimately requiring urgent liver transplantation. Explant histology demonstrated nonspecific massive hepatic necrosis and marked cholestasis. Although the temporal relationship raises suspicion for herb-induced liver injury, causality cannot be definitively established because the herbal preparation was not botanically authenticated or chemically analyzed.