Fulminant liver failure after administration of the herbal antidepressant Kava-Kava

History and clinical findings: A 60 year-old woman was admitted to hospital because of jaundice, fatigue, weight loss over several months and icteric skin. Because of progressive liver failure, concomitant renal failure and p rogressive encephalopathy she was transferred to an intensive care unit. Investigations: Biochemical tests revealed acute liver failure with high le vels of total and conjugated bilirubin (30 mg/dl) as well as aspartate amin otransferase (921 IU/I) and alanine aminotransferase (1350 IU/I) concentrat ions. Prothrombin time was less than 10%. Serological tests could rule out viral hepatitis, metabolic or autoimmune causes of liver failure. On abdomi nal computed tomography and ultrasonography no pathological changes were de tected. Above all portal vein thrombosis, ascites, focal lesions of the liv er and extrahepatic cholestasis could be excluded. Liver histology showed e xtensive hepatocellular necrosis with intrahepatic cholestasis. Treatment and clinical course: The patient's physical condition deteriorate d. She had to be intubated because of respiratory insufficiency and encepha lopathy stage IV. Because of progressive liver failure under conservative t reatment the patient received an orthotopic liver transplant 11 days after admission. Conclusions: The exclusion of other causes and the histological diagnosis m ade Kava-Kava as the cause of acute liver failure most likely. This is the 18th case of Kava-Kava induced liver failure reported to the European regul atory authorities.