Liver Injury After Occasional Energy Drink Use in a Patient Living With HIV and Diabetes

Abstract

Liver injury caused by the use of herbal and dietary supplements is considered a serious problem because of its unforeseeable nature and possibly fatal course. Increasing episodes of liver injury associated with the use of these products have been recently reported, likely resulting from easy access and beliefs among consumers that they are natural, safe, and effective. Here, we report the case of a patient who experienced liver test abnormalities after consumption of an energy drink. The 38-year-old man living with HIV and diabetes had been on maintenance combined antiretroviral therapy with elvitegravir/cobicistat/tenofovir alafenamide/emtricitabine once daily plus metformin 500 mg twice daily for 26 months. At the last visit (May 2019), his HIV-RNA in plasma was not detectable (<37 copies/mL), the CD4+ cell count was 387 cells/mm, and the liver enzymes were within normal limits (aspartate aminotransferase [AST] 22 IU/L, alanine transaminase [ALT] 28 IU/L, γ-glutamyl transpeptidase [GGT] 48 IU/L, and lactate dehydrogenase [LDH] 298 IU/L). At his next scheduled follow-up visit in August 2019, the patient showed a rise in aminotransferases (AST 508 IU/L, ALT 245 IU/L) and LDH (598 IU/L). The patient denied recent/ chronic alcohol abuse (as indirectly confirmed also by the values of GGT of 64 IU/L) as well as taking other prescriptions, dietary supplements, or illegal substances (he had no history of recreational drug use), excluding those chronically prescribed, but reported drinking 1 serving of an energy drink (C4 Sport, see Table 1) before his routine physical training (3-4 times a week), starting 8 weeks before the outpatient visit. The energy drink was immediately discontinued, and after 1 week, the hepatic enzymes normalized (AST 41 IU/L, ALT 48 IU/L, GGT 44 IU/L, LDH 184 IU/L). Hepatitis A, B, C, and E were excluded as well as other causes of hepatic cytolysis such as Epstein-Barr virus, cytomegalovirus, syphilis, or autoimmune diseases; ultrasound of the abdomen revealed no abnormalities. The association between the episode of hepatic injury and energy drink intake was scored as possible or probable (according to the Naranjo Causality Scale) because the abnormal liver function occurred with a reasonable time sequence after starting the energy drink, was unlikely to be attributed to other drugs or concurrent diseases, and followed a clinically reasonable response to supplement withdrawal. Energy drinks are increasingly used by sport practitioners, young students, and active people to improve energy, weight loss, athletic performance, and mental concentration. These products are labeled under food low and not obliged to safety assessments before their marketing. Although several of the ingredients contained in these supplements are known to cause toxicity in cases of abuse/overdose, none of their toxicity profiles include hepatotoxicity, except for vitamin B 3 (niacin). Indeed, in the literature, the few cases in which patients developed elevated aminotransferases after heavy energy blend consumption have been related to the daily ingestion of high quantities of niacin. However, the energy drink taken by our patient contains vitamin B 12 and B 6 but not niacin. Remarkably, besides vitamins B, it contains also specific performance and energy blends, such as creatine, β-alanine, arginine, taurine, and caffeine. This is particularly relevant in light of a recently published research in animals (rats) showing that the combination of energy drink ingredients may be responsible for the augmentation of oxidative stress and liver histopathological abnormalities, especially when combined with ethanol. Our patient, who did not take alcohol was, however, a man living with HIV and diabetes, 2 conditions known to induce oxidative stress. 883811 AOPXXX10.1177/1060028019883811Annals of PharmacotherapyCattaneo et al letter2019