Etiopathogenic and Therapeutic Considerations in a Multiple Sclerosis Case with Acute Toxic Hepatitis

Background/Objectives: In multiple sclerosis (MS) there are many therapeutic options, most of the available drugs causing drug-induced liver injury, after the first infusions. A wide variety of other drugs may cause a spectrum of liver disease, from simple anti-pyretic drugs like paracetamol to multiple dietary herb supplements like Ashwagandha. Methods: 39 years female patient, diagnosed with MS, previously treated with Glatiramer Acetate, Interferon-beta, and current immunomodulatory treatment with Natalizumab (infusion no. 81), with recent history of an airway infection for which she took 4-5 capsules of Paracetamol per day for 7 days, and consumption of dietary supplement with Ashwagandha herbs, who presented with jaundice, pruritus, and lower limbs ecchymoses. Results: Laboratory results revealed higher aminotransferases levels, total bilirubin, and alkaline phosphatase. Screening for autoimmune and infectious hepatitis was negative. The scenario of a toxic hepatitis induced by recently used drugs (Ashwagandha dietary herb supplement and Paracetamol) made the medical team to start therapy with oral prednisone. The clinical and laboratory results progressively improved, with normal levels in liver enzymes and bilirubin, with no further increase after discontinuation of corticosteroid therapy and dietary herb supplement.  Conclusions: This case highlights the difficulty to establish the multiple etiologies and the management of an acute hepatitis in a MS patient with Natalizumab as immunomodulatory treatment, a drug that can induce liver injury after the first infusions, and with recent history of ingestion of toxic hepatic drugs.