MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

Tinospora cordifolia, a plant used in Ayurvedic medicine, is a widely grown glabrous, deciduous climbing shrub which has been described in traditional medicine texts to have a long list of health benefits. It contains diverse phytochemicals, including alkaloids, phytosterols, glycosides. Preparations utilize the stem and root of the plant which is consumed in the form of capsules, powder, or juice or in an unprocessed form. Its benefits are said to include anti-inflammatory, anti-pyretic properties, anti-viral and anti-cancer, and immune-boosting properties. The latter alleged activity made it popular during the pandemic. Indian researchers recently reported 6 patients who presented with liver injuries after taking Tinospora cordifolia.

Case 1

A previously healthy 40- year-old male without comorbidities, presented with jaundice of 15 days duration. On persistent probing, he gave a history of consumption of TC plant twigs (10 to 12 pieces) boiled with cinnamon and cloves in half a glass of water, once in two days for 3 months prior to presentation. USG of the abdomen was unremarkable. He underwent a percutaneous liver biopsy which showed features of the hepatocellular pattern of liver injury – with lymphoplasmacytic cell infiltrate, interface hepatitis, and foci of necrosis – suggesting the diagnosis of DILI with autoimmune features. He was managed with standard medical treatment (SMT) which included multivitamins and ondansetron for associated nausea. He was followed up for 5 months till the complete resolution of symptoms and normalization of liver function.

Case 2

A 54- year -old female, with type 2 diabetes mellitus, presented with jaundice for 1 week. A 7-month history of unsupervised consumption of TC plant (1 twig per day), which was boiled and extract consumed – was obtained. Evaluation for cause revealed a positive ANA (1:100), negative ASMA, negative viral markers, and normal IgG. USG features showing a liver with coarse echotexture, spleen of 13.4 cm, and minimal free fluid in the abdomen. A percutaneous liver biopsy showed a mixed pattern of liver injury (hepatocellular and cholestatic) with features of lymphocytic, neutrophilic and eosinophilic infiltrate, prominent interface hepatitis, intracytoplasmic and canalicular cholestasis, and altered architecture. She was managed with SMT. In view of chronicity, she was started on oral prednisolone in a dose of 40 mg which was tapered over a period of 10 weeks following which there was the resolution of her symptoms, improvement in LFTs and she was advised regular follow up.

Case 3

A 38- year-male with Beta-thalassemia minor presented with jaundice of 1-week duration. He gave a history of consumption of 3-4 TC plant twigs – boiled and extract consumed 15 ml/day for 6 months prior to presentation. Work up for the etiology showed a positive ANA (1:100). USG showed hepatomegaly (16 cm) with diffuse fatty infiltration and splenomegaly (17.3 cm). A percutaneous liver biopsy suggested the diagnosis of drug-induced hepatitis with a hepatocellular pattern of liver injury along with moderate lymphocytic infiltrate admixed with plenty of eosinophils and few plasma cells, mild interface hepatitis. He was managed with SMT and followed up until complete resolution of symptoms and LFTs.

Case 4

A 62- year-old female with type 2 diabetes mellitus, presented with complaints of malaise, reduced appetite and yellowish discoloration of urine, eyes, and skin with abdominal distension for 15 days. She confirmed consumption of commercially available syrup containing TC plant – 15 ml/day, every alternate day for a month, prior to the onset of her symptoms. Investigations revealed a positive ANA (1:320) and ASMA. Imaging showed hepatomegaly and ascites. A trans-jugular liver biopsy suggested a diagnosis of autoimmune hepatitis suggested by lymphoplasmacytic infiltrate with eosinophils and neutrophils, as well as interface hepatitis. There was also cirrhosis suggested by marked lobular disarray, pseudo-glandular transformation, and bridging hepatic fibrosis. She was treated with standard medical therapy including a low salt diet and diuretics for ascites and started on oral prednisolone 40 mg per day. She initially showed clinical improvement and improving trends of LFTs. However, on tapering of steroids, she came back with increasing ascites and oliguria and succumbed to hepato-renal syndrome around 120 days from the first presentation.

Case 5

A 56- year-old female with hypothyroidism presented with yellowish discoloration of urine and eyes. A short, 3-week history of consumption of TC plant boiled extract of 1 twig, 2 to 3 days/week was obtained. Standard investigations for etiology were negative except for a high serum IgG of 2570 mg/dl. The auto-immune markers were negative. USG showed mild ascites, nodular liver, and spleen of 12.3 cm. A trans-jugular liver biopsy showed lymphoplasmacytic infiltrate admixed with plasma cells and eosinophils, moderate interface hepatitis, fibrosis, and altered architecture suggestive of auto-immune cirrhosis. SMT and tapering doses of prednisolone starting with 40 mg orally over 6 weeks led to the resolution of symptoms with the improvement of LFT. She was continued on a maintenance dose of steroids and advised to close follow-up.

Case 6

A 56- year-old female, with hypothyroidism presented with jaundice of 20 days duration. History of TC plant formulation in the form of commercially available tablets – 1 pill a day, for 3 months prior to presentation was obtained. Routine evaluation for the cause of liver injury showed a weakly positive ASMA and a high serum IgG (2045 mg/dl). ANA was negative. USG showed diffuse heterogeneous echotexture of liver and normal-sized spleen. A percutaneous liver biopsy showed chronic hepatitis with lymphoplasmacytic infiltrate, interface hepatitis with significant bridging fibrosis suggesting the possibility of autoimmune hepatitis. She was managed with SMT, leading to complete symptomatic and biochemical resolution. There was no relapse of hepatitis after stopping TC and a follow-up of 2 months.

 

The authors believe that the liver injury seen in these patients was caused by autoimmune-like hepatitis due to consumption of TC, or the unmasking of latent chronic auto-immune liver disease. Most drug-induced autoimmune liver injuries are an acute idiosyncratic reaction which was also supported by the fact that one patient taking the drug for only 3 weeks on alternate days.

9 Responses to Herbal remedies are good for you … except for the ones that injure your liver

  • Its benefits are said to include anti-inflammatory, anti-pyretic properties, anti-viral and anti-cancer, and immune-boosting properties. The latter alleged activity made it popular during the pandemic.

    [emphasis added]
    Could this be a rare case where the claim of ‘immune-boosting properties’ may actually hold some water? If so, it would be a good example of why ‘boosting the immune system’ is not a particularly good idea:

    The authors believe that the liver injury seen in these patients was caused by autoimmune-like hepatitis

    In all fairness, I can’t find any information on the actual mechanism, and as the authors state, chances are that those patients had a latent autoimmune disorder already. Also see https://www.hopkinsmedicine.org/health/conditions-and-diseases/hepatitis/autoimmune-hepatitis

    Generally speaking, I think it would help if people realized that particular herbs and plants having therapeutic effects is a matter of rare coincidence, not the rule. I’d even say that the opposite applies: chances are that any arbitrary plant is harmful if ingested, not beneficial – which is also logical from an evolutionary point of view: in most cases, being eaten is not good for survival, and one of the more common evolutionary paths to deter being eaten is to develop toxicity. There is no good evolutionary explanation for the opposite, i.e. plants developing medicinal properties.
    By chance, some of these toxins or their metabolic by-products may have therapeutic effects, but then they will almost inevitably also have side effects.

    There appears to be quite a lot of research into the medicinal properties of Tinospora cordifolia, but so far, I failed to locate any definite positive evidence for those claims (although I can’t access the actual text of most of what I found). One sentence in an abstract caught my eye though:
    “The work carried out by researchers using extracts of Tc in various areas such as diabetes, liver damage, free radical mediated injury, infections, stress and cancer have been reviewed.” [emphasis added]
    I am quite curious to read what the findings were in treating liver damage with this herbal ‘medicine’….

  • Oh dear, you seem to be scraping the barrel with this ‘exposure’ Edzard? Peeps around the world have taken ‘herbal remedies’ for thousands of years … so what? A recent report in the UK highlighted the dangers of eating wild mushrooms when a family out in the woods ate said wild mushrooms, then became very ill as a consequence.
    Mainstream medicine delights in highlighting the potential dangers of anything that cannot be Patented as a licensed medicine or drug. And during covid, I have even read claims from General Practitioners warning that Vitamin D can be toxic; they stick to the pathetic one-size-fits-all recommendation of no more than 400 IU’s per day, regardless of how deficient a person might be in this important multi-tasking nutrient. Vitamin D (the active form being Calcitriol) is not a magic bullet – it works alongside a number of other important substances to help support the immune system.

  • Your response Edzard is not worthy of your qualifications and experience. Instead of using intelligent counter-argument you chose to belittle my comments… that is the hallmark of a lazy person, unable to respond with anything useful or informative for the benefit of other readers. As the saying goes: “move on, nothing to see here”.

    • I did not belittle your comments; they WERE little.

      • @EE

        I won’t loose the time to do it, but I bet I could come up with an exhaustive list of Pharma meds or treatments that MIGHT injure your liver. I’m sure there would be more than six such candidates.

        Without even touching medicine, how about the multiple forms of FDA approved alcohol drinks ?

  • Another example of ‘alternative’ medical practice that may shock you:

    https://www.bbc.co.uk/news/uk-england-humber-58116324

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