“Acute Fulminant Hepatic Failure in 23-Year-Old Female Taking Homeopathic Remedy” is not a title we see often on a scientific paper. Naturally, it attrackted my interest. In the paper, a US team presented a case of a 23-year-old otherwise healthy woman with body mass index 32.3 and a history of polycystic ovarian syndrome who presented with acute liver failure (ALF) ultimately requiring orthotopic liver transplantation. The patient was originally from India where she reported taking homeopathic medications for various indications for several years without known toxicity. She had no history of alcohol, tobacco, or other drug use. At the time of her presentation, she was living and working in the US and reported she was unable to refill her homeopathic product with the primary ingredient of eggshells from India. She was off of all medications and supplements with the exception of Berberis vulgaris for approximately 1 month before obtaining a similarly named homeopathic product with the primary ingredient of eggshells from Amazon. She reported originally taking 4 pills/d for 10 days, and then increased to 10 pills/d for 10 days as she was unsure of the appropriate dose.

She subsequently developed orange discoloration of her urine and nausea, reportedly without any preceding muscle-related effects or symptoms, and she discontinued all of her medications/supplements. Approximately 2 weeks later, she presented to the emergency department for nausea and malaise, where a blood test revealed abnormal liver enzymes. Mononucleosis screen and hepatitis panel were negative. She had no evidence of hepatic encephalopathy at that time. Ultrasound of the abdomen was notable for hypoechoic liver parenchyma only.

She was discharged home with gastroenterology telehealth follow-up. She was seen 1 week later and reported worsening nausea, vomiting, anorexia, jaundice, and fatigue. She presented to a local emergency department where she received intravenous vitamin K and underwent further laboratory evaluation. She was transferred to another hospital for higher level of care and admitted with acute liver injury. There she received intravenous N-acetylcysteine per institutional protocol, ursodiol, albumin, vitamin K, and fresh frozen plasma transfusions given for coagulopathy. Magnetic resonance cholangiopancreatography was performed and demonstrated no evidence of biliary obstruction or chronic liver disease (no ascites, contour nodularity, mass, or lymphadenopathy), though liver size noted to be small (11.5 cm in span). At 21 to 28 days after the onset of symptoms, her lab results were still highly abnormal and her mental status deteriorated. She was intubated for airway protection given severe encephalopathy, “cooling protocols” were initiated, and she was transferred again to a higher level of care at a center for emergent liver transplant evaluation. She was evaluated and listed as status 1A for acute liver failure. Her clinical status continued to decline and her labs continued to worsen.

An appropriate organ became available 28 hours after listing. At the time of her surgery, her explanted liver was noted to have massive parenchymal loss with hemorrhage, and pathology confirmed near complete collapse of the organ’s framework with only small foci of steatotic hepatocytes remaining. After her initial operation, her hospital course was complicated by coagulopathy, hypotension, leukocytosis, kidney failure requiring temporary dialysis, and multiple operations for completion of biliary anastomoses and delayed complex abdominal wall closure with mesh given large donor size. She was discharged from the hospital 2 weeks after transplant and her outpatient course continues to go well over 1 year after liver transplantation.

The product in this case has not been previously reported to be toxic. Its primary ingredient is calcium from “toasted eggshells,” which is also not generally known to cause liver failure or disease. However, the authors point out that it is not uncommon for supplements such as this one to contain other potentially toxic agents that are not specifically listed on the bottles’ label. For example, toxic metals including lead, mercury, and arsenic have reportedly been discovered in many (almost 20%) naturopathic medicines manufactured in India, particularly those sold by US websites. As such, the authors hypothesize that this patient’s ALF was likely caused by a contaminant (also consumed in higher quantities than intended) in her homeopathic product with the primary ingredient of eggshells.

The authors of this paper repeatedly state that the product was a homeopathic remedy; however, on other occasions they claim that it was a herbal supplement. In their Figure 1, they name the product as ‘OVA TOSTA’; on Amazon USA, I did indeed find a remedy by that name. Sadly, I was unable to obtain any information about its exact ingredients or composition.

Regardless whether the product was herbal or homeopathic, this case report is a poignant reminder that, in so-called alternative medicine (SCAM) many dangerous remedies are offered for sale. Therefore, it is advisible to be cautious and insist on sound information about the quality, safety, and efficacy before trying any such therapy.