Tinospora Cordifolia (Giloy)-Induced Liver Injury During the COVID-19 Pandemic-Multicenter Nationwide Study From India

Abstract

Tinospora cordifolia (Giloy) is an herbal supplement commonly used in the Indian alternative medicine system Ayurveda. This herb has been promoted to the public in India as an immune booster to prevent novel coronavirus disease 2019. However, small reports have recently shown an association between Giloy use and the development of herb-induced liver injury (HILI) with autoimmune features in some patients. This large retrospective Indian multicenter study spanning 13 centers at nine locations was designed to identify features and outcomes of HILI temporally associated with Giloy use. Chemical and toxicological analyses of retrieved Giloy samples using state-of-the-art methods were also performed. We report 43 patients, of whom more than half were female, with a median time from initial Giloy consumption to symptom onset of 46 days. Patients presented with acute hepatitis, acute worsening of chronic liver disease (CLD, the most common clinical presentation), or acute liver failure. Causality assessment revealed probable liver injury in 67.4%. The most common autoantibody detected was anti-nuclear antibody. Liver biopsy in a subset revealed HILI associated with autoimmune features and hepatocyte and canalicular cholestasis and neutrophilic and eosinophilic infiltration. Conclusion: Giloy is associated with acute hepatitis with autoimmune features and can unmask autoimmune hepatitis (AIH) in people with silent AIH-related CLD. Further studies on the safety (and efficacy) of untested but heavily promoted herbals in alternative systems of medicine are an unmet need in the interests of public health and are especially important during this global health emergency.

FIG. 1

Some of the Giloy‐based formulations as well as raw Giloy plant retrieved from patients with HILI.

FIG. 2

Liver histopathological features of patients with Giloy‐induced liver injury. (A) Mixed inflammatory reaction in portal and lobular regions in patient with underlying chronic liver disease (hematoxylin and eosin [H&E] stain, ×10), (B) Confluent necrosis associated with neutrophilic and lymphoplasmacytic inflammation (H&E stain, ×40). (C) Ballooning of hepatocytes with perivenular necrosis (H&E stain, ×100). (D) Moderate interface hepatitis with mixed inflammatory infiltrate (H&E stain, ×100). (E) Canalicular bile plugs (H&E stain, ×200). (F) Eosinophilic infiltration amidst neutrophils and plasma cell rich inflammation (H&E stain, ×200).

FIG. 3

Infographic summary.