NEOBUXBAMIA TETETZO AS A CAUSE OF DRUG-INDUCED LIVER INJURY

Introduction and Objectives

Drug-induced liver injury (DILI) is a rare clinical condition, the incidence is estimated from 14 to 19 cases per 100,000 population per year, it is responsible of 3 to 5% of jaundice hospitalizations, and it is the most frequent cause of acute liver failure in many of the western countries. Neobuxbaumia tetetzo is a species of flowering plant of the Cactaceae family, endemic to Mexico, distributed in Puebla and Oaxaca, and has been used within Mexican cuisine, without studies that establish the safety of its consumption, which predisposes to undocumented adverse effects, including probable liver injury.

Materials and Methods

The patient is a 19-year-old male, high school student and employee of a private company, single, originally from Tehuacán, Puebla, resident of Mexico City. Non-relevant family hereditary background. He denied experiencing any chronic degenerative diseases, allergies or traumas, but reported complications during an appendectomy in May of 2019. Has positive alcoholism, consuming it occasionally in social events; last consumption was seven months prior to the onset of symptoms. He denied the use of drugs, food supplements and herbalism. He began in June 30th of 2020 with asthenia, hyporexia, adinamia, nausea and unquantified fever, pain in epigastrium of moderate intensity, generalized pruritus, conjunctival jaundice and coluria were added, progressed to generalized jaundice, required hospitalization in August 2020. The laboratory results are Total Bilirubin 38.5 mg/dL, Direct bilirubin 26 mg/dL, ALT 60, AST 63, AP 329, GGT 33, General urine test that evidenced bilirubins 6 and urobilinogen 8. An ultrasonography and an abdominal tomography were performed, both reporting vesicular lithiasis, without obstruction or dilation of the bile duct. Subsequently, cholangioresonance was carried out on September 9, 2020, reporting liver gland with homogeneous parenchyma, bile duct without intra and extrahepatic dilation, gallbladder with the presence of lithic of 6.5 mm. Cholecystectomy and liver biopsy were performed, with histopathological result of gallbladder with chronic cholecystitis. Liver biopsy reporting: Hepatic parenchyma with preserved architecture, with few plasmatic and eosinophilic cells, and presence of severe intracanalicular and intracytoplasmic cholestasis corresponding to regenerative changes of grade 0 fibrosis on the Metavir scale and focal microvesicular steatosis, without regeneration nodules. Within its approach, serology Anti-Sm, IgM vs. CMV, IgM vs. Rubella, IgM vs. Toxoplasma, ANAs, anti Ro, SCL70 antibodies, HBV, HCV were negative.

Discussion and Conclusion

The only finding observed in the clinical case of our patient that we can appreciate is the elevation of bilirubin. After ruling out the main and possible causes that affected the health of our patient, it was decided to re-interrogate him and it was found that the patient had an antecedent of consumption of N. tetetzo, this highlights the importance of the clinical history in the approach of DILI and the need for of a clinician to contemplate this possibility. Although in this case, a RUCAM score of 6 points was calculated which makes the diagnosis possible, the score was created in order to avoid biopsy given that it is invasive; and before an anatomopathological finding compatible with DILI it is doubtful whether it is worth rechallenging the patient to the consumption of N. tetetzo to objectify the condition of bilirubins before exposure, there is a risk of acute liver failure, which creates an ethical dilemma and violates the principle of non-maleficence.

The authors declare that there is no conflict of interest.