Acai Berry Induced Cholestatic Jaundice

A previously well 52-year-old gentleman presented with a 2-week history of itch, jaundice, lethargy, pale stools and dark urine. He had no risk factors for liver disease. On systematic questioning, the only new addition to his diet was an acai berry supplement drink to promote weight loss. Blood tests revealed markedly raised bilirubin and ALP, and slightly raised AST and ALT. Ferritin was also raised but was felt to represent an acute phase reactant. The remaining liver screen was unremarkable. Imaging showed a 12 mm hemangioma in segment VII of the liver but was otherwise normal, with no ductal dilatation noted. ERCP revealed normal ducts. Liver biopsy was performed and this revealed hepatocellular and canalicular cholestasis with minimal parenchymal inflammation. Portal tracts were inflamed with lymphocytes. Findings were felt to be consistent with ductal obstruction or drug reaction. Overall findings were felt to be in keeping with a drug reaction secondary to the acai berry supplement. He had been commenced on prednisolone, ursodeoxycholic acid, cholestyramine, lansoprazole and chlorphenamine in a district general hospital prior to transfer to the Liver Unit. On arrival, naltrexone was added to the regimen. His bilirubin peaked at 284 µ mol/L but soon decreased, and returned to normal levels within 2 months. High levels of D-aspartate are found in these berries, and this amino acid is involved in a pituitary pathway involved in stimulation of testosterone production. Alongside anabolic steroids, androgenic steroids have also been shown to be involved in development of cholestatic jaundice. Beta-sitosterol is also found in the berries and is a precursor of boldenone which is an anabolic steroid. These steroid pathways are among the hypotheses for development of cholestatic jaundice in this gentleman. J Med Cases. 2014;5(6):373-375 doi: http://dx.doi.org/10.14740/jmc1794w