Toxic hepatitis-associated aplastic anaemia after dual homeopathic remedies and Gymnema sylvestre use

Abstract

Hepatitis-associated aplastic anaemia (HAAA) is a rare condition characterised by onset of acute hepatitis which is followed by development of severe pancytopenia due to bone marrow failure within 6 months. This syndrome can be precipitated by acute viral infections, but the aetiology remains unknown in the majority. Drug-induced HAAA is extremely rare and has been reported with nutritional and dietary supplements in current literature. We report the first cases of ayurvedic herbal and homeopathic remedies-associated HAAA in two patients which proved fatal in both. Evaluation of patients with acute hepatitis and severe pancytopenia must include a detailed evaluation for complementary and alternative medicine use.

Keywords: drugs and medicines; gastrointestinal system; hepatitis other; liver disease; toxicology.

Figure 1

Retrieved homeopathic remedies (A) and Gymnema sylvestre powder (B) from patients who developed acute hepatitis-associated aplastic anaemia.

Figure 2

Liver histopathology—showing areas of lobular disarray, predominant lobular inflammation (A, H&E 10×); lymphocytic inflammation of the lobular and perisinusoidal areas (B, H&E 40×); hepatocyte fallout (cytolysis) and necrosis in zone 3 (C, H&E, 40×); spotty necrosis and lobular disarray in second patient (D, H&E 10×); intracanalicular (E) and hepatocellular cholestasis (F) noted in second patient (H&E, 100×); bone marrow biopsy showing hypocellularity and trilineage hypoplasia without haemophagocytosis or fibrosis, consistent with aplastic anaemia.