In December 2000, a previously healthy girl aged 14 years reported the
onset of nausea, vomiting, decreased appetite, weight loss, and fatigue. One
week later, the patient had scleral icterus and was hospitalized with acute
hepatitis. During late August to mid-December 2000, the patient reportedly
used two kava-containing products. One product was taken intermittently in
accordance with package directions (two capsules once daily). The patient
estimated that she used the product on approximately 44 days during this period.
The patient reported taking the second product in accordance with package
directions (two capsules once daily) for 7 consecutive days at the beginning
of the 4-month period. Because the product labels were unavailable, other
product ingredients were unknown. The patient reported no use of alcohol or
medications other than occasional ibuprofen. At the time of hospitalization,
the patient's liver-function tests were markedly abnormal (alanine aminotransferase:
4,076 U/L, aspartate aminotransfease: 3,355 U/L, gamma-glutamyltransferase:
148 U/L, total bilirubin: 16.2 mg/dL, ammonia: 17 mg/dL, and prothrombin time:
29.4 seconds).5 Tests for human immunodeficiency
virus (HIV), cytomegalovirus, Epstein-Barr virus, Wilson's disease, a-antitrypsin
deficiency, antinuclear antibodies, and hepatitis A, B, C, and E were negative.
Initial liver biopsy revealed active fulminant hepatitis with extensive centrilobular
necrosis, approximately 25% hepatocellular viability, and mixed inflammatory
infiltrates consisting of lymphocytes, histiocytes, scattered eosinophils,
and occasional neutrophils. No viral cytopathic changes were identified, and
immunohistochemical stains for hepatitis B surface and core antigens were
negative. The patient underwent successful orthotopic liver transplantation.
Pathological examination of the native liver revealed active fulminant hepatitis
with total hepatocyte necrosis and extensive parenchymal infiltration by lymphocytes,
histocytes, and occasional eosinophils.5 The
patient resumed daily activities following recovery from the procedure.