Medical mystery: Common symptom, uncommon cause

As I went through my patient notes one night in the ER, I thought about how strangely quiet the last few hours had been. Just then, I heard the doors slam as the police rushed in with a man in his late 20s. He was delusional and psychotic.

His mother arrived and told me that she had to call 911 when her son started waving a knife, threatening to kill her. She said that he had stopped bathing in recent days, and then she noticed that he was extremely paranoid. He had hardly any appetite - and, she recalled, the whites of his eyes had looked yellow for the last few weeks.

His behavior reminded her of how he acted the previous year, when he was diagnosed with schizophrenia. He refused to take the medications he was prescribed, or to go back to the doctor. He spent his time alone, usually reading books. He didn't use alcohol or any illicit drugs, she told me.

We gave him sedatives and antipsychotic medication. I also ran a urine test to rule out any drug abuse. As his mother predicted, the results were negative.

The next day, he appeared calm and oriented, talking to his mother sitting by his bedside. His mood and behavior had remarkably improved. But his skin looked yellow.

Yellowing of skin, or jaundice, occurs with a rise in the pigment bilirubin, an orange-yellow substance made during the normal breakdown of red blood cells. A higher-than-normal bilirubin usually means a liver problem or problem with the duct that drains bile from the liver. Blood work showed a very high level of bilirubin and alkaline phosphatase, but otherwise normal liver enzymes. An ultrasound, done to see if there was any blockage to the bile duct, was negative. Other blood tests looking for disease affecting the liver and bile duct were also negative.

I thought of drug-induced hepatitis. But the patient was not on any prescription medications. I went ahead and ordered a liver biopsy. To my surprise, his liver showed changes compatible with drug-induced cholestatic hepatitis.

Simply put, his bile flow was impaired, and his lab tests suggested that he was taking some kind of drug that was having a toxic effect on his liver - but what, I thought, could that drug be?

After reading the report, I hurried to my patient's bedside to ask another question: Was he taking any over-the-counter medicines or dietary supplements?

He said he had recently read about the popular folk medicine goldenseal root powder, and decided to try it. He said it was the only herbal medication he had been taking in recent months.

I told him to stop taking it right away. Sure enough, his liver function panel gradually improved and after he'd left the hospital, continued follow-ups showed that he kept getting better.

So I was convinced the goldenseal root was the problem, yet I could find no report connecting it with liver injury. Also called Chinese goldenseal, eye balm and eye root, it contains the chemical berberine. It has been labeled as an antimicrobial, anti-infective, anti-cancer drug. Claims have been made for its powers to treat diabetes, urinary disorders, skin, mouth and eye infections, local inflammation, and high cholesterol levels.

More and more people are turning to "natural" or "alternative" medicine without professional guidance on what it is, what it does, and how it may interact with other medications.

The take-home message is two-fold: First, not everything labeled natural is healthy. What may be fine for some people can have unpredictable effects in others, such as my patient.

Second, as physicians, we should always ask about any over-the-counter medications and supplements.

Dhruvan Patel, M.D., is an internal medicine resident at Mercy Philadelphia and Mercy Fitzgerald Hospitals.

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