A 55-year-old-male was admitted due to dark urine and jaundice. Before admission, he took two capsules of artemisinin extract (containing 200 mg artemisinin extract + 10 mg alkaloid) per day for 1 month for shoulder pain. Gradually, he developed symptoms such as loss of appetite, tiredness of oil and itchy skin. He had no abdominal pain, vomiting, fever, diarrhea, etc. He has no history of hypertension, diabetes, hepatitis and tuberculosis. He did not smoke or drink alcohol. Physical examination revealed tachycardia. His BMI was normal (22.22 kg/m2).
Abnormal liver function was found on admission (e.g., serum alanine aminotransferase of 908 IU/L [normal: 10-55 IU/L], total bilirubin 151.0 umol/L [normal: 3-22 IU/L], direct bilirubin 83.4 umol/L [normal: 0.5-7 IU/L], indirect bilirubin 83.4 umol/L [normal: 3-15 IU/L], blood ammonia 40 umol/L [normal: 9--33 IU/L]. International normalized ratio (INR) was normal. His glycated hemoglobin (HBA1c) was high (8.70%). Tests for hepatitis A, B, C, D, E, and Epstein-Barr virus were negative. Alpha-fetoprotein, carbohydrate antigen 19-9, ceruloplasmin, and antinuclear antibody ANA were negative. Anti-mitochondrial M2 antibody was weakly positive (+-). Laboratory tests did not support known infection (white blood cell, procalcitonin, cytomegalovirus CMV-DNA, human immunodeficiency virus type I type II, Treponema pallidum antibody were all negative).
Resonance Cholangiopancreatography of upper abdomen showed a decreased liver uptake and bile duct excretion of Gd-EOB-DTPA, suggesting liver function impairment (Figure 1). He was diagnosed with drug-induced liver injury, hepatocellular injury type (R ratio 9.3), acute, RUCAM eight points (very likely), severity level three. After admission, polyene phosphatidylcholine, reduced glutathione, ursodeoxycholic acid capsules, and insulin were given. Bilirubin continued to rise after artemisinin was discontinued. On day 12, 14, and 18 after admission, plasma exchange plus bilirubin adsorption therapy was performed three times. His symptoms improved and discharged on day 22. Bilirubin decreased to baseline after 40 days (Figure 2).