Drug- Induced Liver Injury from Over-the-Counter Nutritional Supplement Complicated by Bone Marrow Failure

Introduction: Over-the-counter (OTC) supplements are frequently consumed by patients, and it is imperative for physicians to be aware of this when conducting a history and physical. We present a case of a middle-aged male who experienced drug-induced liver injury and consequent bone marrow failure as a result of an OTC testosterone and metabolism supplement. Case Description/Methods: A 43-year-old man with no significant medical history presents with a 2-week history of dark urine and diffuse pruritus. The patient has a history of smoking and heavy alcohol abuse. The patient works as a chemical compounder at a detergent factory and regularly wears an N95 mask. Of note, the patient has been taking an OTC testosterone and metabolism supplement for over one month. The patient’s labs are notable for a normal CBC without leukocytosis. Labs reveal significantly elevated liver enzymes with an alanine transaminase (ALT) of 3,285 and aspartate aminotransferase (AST) of 2,913. Liver biopsy demonstrates moderate to marked inflammatory infiltrate in the lobular parenchyma and portal tracts consistent with drug-induced liver injury. The patient received IV N-Acetylcysteine for 5 days. Labs improve with ALT and AST decreasing to 1,300 and 1,800 respectively over the next five days. One week later, labs reveal pancytopenia, and the patient is referred to hematology. Over the next three months, the patient has continued pancytopenia, and, in particular, severe thrombocytopenia. Three bone marrow biopsies show repeated hypocellular bone marrow (approximately 30% to 10%-15% to 20% cellularity) with trilineage hypoplasia, no dysplasia or evidence of lymphoid neoplasm. The patient is evaluated for stem cell transplant. The patient is started on a trial of eltrombopag 150 mg daily for 1 month but discontinues it after an asymptomatic period. Over the next year, the bone marrow function slowly improves, and labs show recovery. Discussion: Occasionally, patients do not consider the risk of consuming OTC supplements. It is important for physicians to regularly perform medication reconciliations to ensure the health of a patient. Previous reports and reviews have shown the negative impact of OTC testosterone supplements on the liver, though none of have reported adverse effects on the bone marrow. The likely cause of this patient’s acute hepatitis and subsequent bone marrow failure is a combination of the testosterone supplement use and toxic occupational exposure.