Acute hepatitis and acute kidney insufficiency caused by ingestion of raw grass carp gall bladder

Dear Editor, A 25-year-old male patient entered the emergency room (ER) with complaints of vomiting and numerous watery diarrhoeas. After consuming raw grass carp bile, he developed abdominal cramps with repeated vomiting and watery diarrhoea for 36 h. At his arrival at the ER, he was acutely ill looking and vital signs were as follows: blood pressure, 122/69 mmHg; pulse rate, 69/min; respiration rate, 20 breaths per minute; and body temperature, 37.2°C. On physical examination, abdomen was soft and not distended. He did not have any medical history and was not on any kind of medication. Bowel sound was hyperactive and mild tenderness was noted around the lower abdomen area. He was suspicious of acute food poisoning and blood and stool samples were ordered. Laboratory tests revealed serum aspartate aminotransferase (AST) of 7836 (10–44) IU/L and alanine transferase (ALT) of 7479 (10–44) IU/L, total bilirubin of 3.01 (0.2–1.2) mg/dL, direct bilirubin of 1.98 (0–0.4) mg/dL, total bilirubin 2.0 (0.2–1.2) mg/dL, prothrombin time (15.3 s, 75%, INR 1.21), blood urea nitrogen (BUN) of 32.0 (7–20) mg/dL, serum creatinine of 2.33 (0.6–1.3) mg/dL, and urinalysis revealed no signs of proteinuria or albuminuria. Plain radiography was normal. Serology for hepatitis was negative and no other hepatotoxin was identified. Ultrasonography revealed a mildly coarse parenchymal echogenicity with no evidence of liver cirrhosis and ascite and mild cortical echogenicity increase of both kidneys. His stool and blood sample for culture came back negative. He was admitted under impressions of acute toxic hepatitis and acute kidney insufficiency. During admission he was treated conservatively and a series of laboratory tests were ordered. AST and ALT were normalised in 6 days and BUN and creatinine were normalised in 5 days. He was discharged in 11 days and returned to daily life. In some countries of Asia, fish gall bladder and carp bile were handed down by oral tradition as a remedy for hypertension and detoxification and favoured as a herbal tonic. However, its use as medicine is not scientifically proven and some cases of toxicity of raw carp gall bladder have been reported. Clinical symptoms after ingestion of raw fish bile are non-specific as general weakness, anorexia, cramping abdominal pain, nausea and vomiting. Also, oliguria and oedema are noted as signs of acute kidney insufficiency. Symptoms vary from gastroenteritis from mild intoxication to moderate intoxication involving the kidney and liver, to severe intoxication causing multi-organ failure. Two studies had revealed that 5a-cyprinol and 5a-cyprinol sulfate from grass carp bile could be responsible for acute kidney insufficiency and toxic hepatitis. In an in vivo study, raw carp bile caused multiple focal necrosis in the liver and renal oedema in rat; however, a clear mechanism has not been identified yet. Although deaths have been reported in some severe cases, most patients recovered without complications and conservative treatment was sufficient. There were some cases of raw carp bile-induced acute hepatitis and renal insufficiency in a few countries; however, since the year 2008, no case of ingestion of raw carp bile has been reported in South Korea. Despite the widespread use of basic public health food safety and hygiene measures, it is surprising that some people still believe that ingestion of raw carp bile can improve health. An aspect of this case that caught our attention was the recurrence of complication of herbal or traditional medicine. With efforts from public healthcare and education, the reckless trial of unproven traditional herbal medicine seemed to decrease in our society. Only seven case reports for raw carp bile-induced complication were found in PubMed. In the United States, there were only two cases of acute hepatitis and renal failure following ingestion of raw carp gall bladder and they were immigrants from South Korea and Cambodia. As we can see from the two cases reported in the United States, immigrants from developing countries might influence the rate of diminishing cases of intoxication from consuming herbal medicine. Therefore, we need to be more alert and cautious. The trend in increase of intoxication incidences needs to be studied further with more data.