A Rare Case of Severe Liver Injury Related to Whey Protein Supplementation

1981

Drug-induced liver injury (DILI) is an important cause of iatrogenic liver injury. It is the most common cause of acute liver failure in the United States and is the leading cause of drug withdrawal from the U.S. market. Whey protein is a reportedly safe powder supplement that has infrequently been associated with severe liver injury. We report a rare case of whey protein supplement induced severe liver injury in a healthy adult male. A 42-year-old male with a medical history of remote alcoholic pancreatitis presented with painless jaundice for two days associated with fatigue, anorexia, dark urine, insomnia, and weight loss. He endorsed consuming multiple whey protein and creatine supplements during the previous sixty to ninety days prior to admission. He did not take any home medications and denied any history of blood transfusions, recent travel, intravenous drug use, anabolic steroids or sick contacts. Exam was notable for diffuse jaundice, scleral icterus, and two professional tattoos on his abdomen. Laboratory workup was notable for total bilirubin 17.3 mg/dL, direct bilirubin 15.6 mg/dL, AST 187 U/L, ALT 128 U/L, ALP 542 U/L, albumin 2.1 g/dL, LDH 1796 U/L, ferritin 1840 ng/mL, hemoglobin 9.3 g/dL, hematocrit 27.3%, INR 1.2, platelets 104 K/UL, partial thromboplastin time 40.8s, and prothrombin time 14.8s. Hepatitis screen, HIV, Tylenol level and urine toxicology were negative. CT abdomen, MRCP and ultrasound of the liver were only significant for hepatomegaly. Liver biopsy was performed and revealed portal inflammation, ductular reactions associated with neutrophilia and hepatocellular cholestasis suspicious for DILI without features concerning for infiltrative disease. Over the course of the hospital admission, the hyperbilirubinemia and transaminemia improved without progression to fulminant liver failure. This case highlights a rare and infrequently reported cause of DILI related to whey supplement use in a lowrisk individual. The Roussel Uclaf Causality Assessment Method (RUCAM) score was 8, supporting our conclusion of supplement-related liver injury. DILI can be an elusive diagnosis and demands a proper medication and supplement history in addition to serologic and histologic criteria in order to diagnose. Physicians must maintain a high index of suspicion for DILI when evaluating hepatotoxicity in order to properly educate patients regarding discontinuation of offending agents.