1) Several cases of toxic hepatitis have been associated with consumption of nordihydroguaiaretic acid and chaparral tea (Smith et al, 1994; Gordon et al, 1995; Batchelor et al, 1995; Gordon et al, 1995; CDC, 1992; Smith & Desmond, 1993). In one case, ascites was associated with hepatitis and the liver biopsy showed mild to moderate hepatocellular necrosis, mild cholestasis, and mild fibrous septation (Batchelor et al, 1995).
2) CASE REPORT - Subacute hepatic necrosis, with ascites and coagulopathy, following 3 months of ingesting 15 chaparral tablets per day, is reported in a previously healthy 33-year-old female. All signs/symptoms eventually regressed following discontinuation of the chaparral tablets (Katz & Saibil, 1990).
3) CASE REPORT - Severe cholestatic, cholangiolitic hepatitis, with marked elevation of serum hepatic enzyme levels, is reported in a 45-year-old female after 2 months of ingesting 160 mg/day of chaparral tablets. She had a history of alcoholism, but had not consumed any for 2 months. Prior to starting chaparral she had taken lovastatin. She had begun taking chaparral tablets for treatment of alcohol withdrawal (Alderman et al, 1994).
a) Following therapy with corticosteroids, her hepatotoxicity resolved (Alderman et al, 1994). An actual causal relationship, however, has not been established. The authors suggested that chaparral may have potentiated pre-existing liver damage.
4) CASE REPORT - A 60-year-old female presented with signs/symptoms of hepatitis following 10 months of daily chaparral use (1 to 2 capsules). Liver biopsy revealed severe acute hepatitis and areas of lobular collapse and nodular regeneration. Also present was mixed portal inflammation and significant bile ductular proliferation. Liver biopsy supported the theory that an acute injury evolving to chronic liver damage had occurred.
a) Liver failure progressed, requiring a liver transplant. It should be noted that in addition to chaparral, the patient had been taking diltiazem, atenolol, aspirin, nitroglycerin, and occasional acetaminophen (Gordon et al, 1995).
5) CASE REPORT - A 69-year-old male who had taken 14 chaparral compound tablets/day for 6 weeks, developed pruritus, nausea, anorexia, weight loss and jaundice associated with abnormal liver tests. His only other medication was metoprolol, and there was no recent history of any medication or events that would alter liver function.
a) Abnormal lab tests included elevated serum liver enzymes, abnormal albumin and protein. There was no lab evidence for hepatitis A, B, or C, cytomegalovirus or Epstein-Barr virus. Following discontinuance of the herbal containing chaparral, the patient's symptoms and lab abnormalities progressively improved and were normal at 8 weeks. The presence of multiple agents in the herbal preparation and the absence of a re-challenge with chaparral precludes assigning causation to this agent (Shad et al, 1999).
6) CASE SERIES - In a series of 13 cases of hepatotoxicity associated with chaparral ingestions, clinical presentations occurred within 3 to 52 weeks following chronic ingestions. Toxic or drug-induced cholestatic hepatitis was the main presentation, with progression to cirrhosis in 4 patients and acute fulminant hepatic failure in 2 patients (Sheikh et al, 1997).
7) CASE REPORT - A 22-year-old woman presented to the hospital with a one-week history of progressive jaundice and mild abdominal pain. Liver enzyme levels were elevated (ALT 2871 units/L, AST 1773 units/L, alkaline phosphatase 511 units/L). The liver enzyme levels improved and she was discharged 2 weeks post-admission. Two weeks post-discharge, she presented with increased jaundice, fatigue, nausea, pruritus, and epigastric pain. Liver enzyme levels were again elevated (ALT 1084 units/L, AST 862 units/L, alkaline phosphatase 379 units/L). A liver biopsy showed inflammatory infiltration with severe parenchymal damage.
a) She admitted to consuming an herbal preparation containing 61.9% chaparral powder, 2 tablets daily for approximately 8 weeks prior to her first hospitalization. During her first hospitalization, she had discontinued taking the preparation, but 5 days post-discharge she restarted at the same dose. The liver enzyme levels began to gradually normalize and the patient was discharged 5 weeks post-admission. Approximately 9 months after the first liver biopsy was performed, a second biopsy showed mild hepatic fibrosis and inflammation of the portal tract (Kauma et al, 2004).