Cholestatic liver injury from Ganoderma lucidum coffee extract—a case report

Abstract

Background: Drug-induced liver injury (DILI) poses a tremendous diagnostic challenge for physicians owing to the vast array of medications used in clinical practice. In addition, clinicians must also be aware of the recent increase in the consumption of traditional medicine that can lead to herb-induced liver injury (HILI) and portends the risk of acute liver failure. Case Description: We recently encountered a 19-year-old man who presented with painless jaundice, tea-coloured urine and pale stools for 1 week. There was a significant, intentional weight loss of 20 kg 6 months before his presentation. He denied taking any medications. Clinical examination was unremarkable, while notable blood investigations revealed findings supportive of cholestatic liver injury. Extensive second-line biochemical and radiological workup was normal. Liver biopsy demonstrated marked hepatocanalicular cholestasis with an updated Roussel Uclaf Causality Assessment Method (RUCAM) score of 8, thus establishing a probable cause for HILI. Further exploration following recovery revealed a year’s ingestion of premixed coffee with Ganoderma lucidum (Lingzhi) extract as an energy booster to help with weight loss. Given that there were no concomitant hepatotoxins and progressive improvements following cessation of the offending agent, we attributed his cause of hepatotoxicity to HILI from prolonged Lingzhi ingestion. Conclusions: Our case highlights a fundamental yet common pitfall encountered while managing HILI: patients may involuntarily withhold information based on their cultural beliefs and perception of what may or may not constitute a hepatotoxin. In this scenario, Ganoderma lucidum is reputable for its hepatoprotective effect, though there is no conclusive scientific evidence in humans. As demonstrated, such misperception can lead to a highly frustrating diagnostic conundrum resulting in expensive and unwarranted investigations with extended admission for procedures. In the absence of a specific biomarker, careful enquiry of exposure to various drugs and herbal products, preferably with a RUCAM checklist, is pertinent to avoid negligence.