Ayurveda metallic-mineral 'Bhasma'-associated severe liver injury

Abstract

Ayurveda Bhasma is a metallic-mineral preparation homogenised with herbal juices or decoctions and modified with heat treatment to apparently detoxify the heavy metals. It is widely recommended for the treatment of many disease conditions by practitioners of complementary and alternative medicine in the absence of good quality clinical trial evidence on its safety and efficacy. Heavy metal-induced liver injury is widely reported in the literature, and heavy metal adulteration of non-Bhasma-related Ayurveda and herbal products has been well described. We report a patient who developed severe liver injury requiring listing for liver transplantation for improved survival, after consumption of Bhasma for dyspepsia. This case describes the first documented case and toxicology analysis of Ayurveda Bhasma associated with severe drug-induced liver injury. Physicians must be alert regarding patient's use of supposedly safe Ayurveda Bhasma that may promote acute severe liver injury in the absence of other known aetiologies.

Keywords: complementary medicine; drugs: gastrointestinal system; healthcare improvement and patient safety; liver disease; toxicology.

Figure 1

The Ayurveda Bhasma consumed by the patient associated with severe liver injury. Note that there are no content, component and adverse effect disclosures. The package also mentions dosing in children without clear evidence for safety and efficacy in a paediatric population.

Figure 2

Liver histopathology of a Bhasma-poisoned case that revealed extensive periportal and perivenular necrosis (A; H&E, magnification 10×); infiltration of the portal tracts by mixed inflammatory cells (B; H&E, 20×) marked cholangitis, hepatocytic ballooning (C; H&E, 40×), neutrophilic satellitosis (D; H&E, 40×) and severe canalicular and hepatocellular cholestasis (E; H&E, 40×); extensive bridging fibrosis on Masson-Trichrome staining (F, 20×).