The active ingredient, cyproheptadine, can only be purchased legally with a prescription. may include fatigue, nausea, rash, arthralgias, abdominal pain, jaundice, and pruritis. DIAIH responds to corticosteroids and immune suppressors. Hepatitis resolves with the withdrawal of the inciting drug. Associated drugs include antimicrobials (nitrofurantoin and minocycline), interferon, infliximab, and statins.1C3 We statement a rare case of Apetamin (cyproheptadine, lysine, and vitamin syrup) causing DIAIH. The product, manufactured by TIL Healthcare PVT (Chennai, India), a pharmaceutical organization based in India, is composed of active ingredient cyproheptadine 2 g and L-lysine 150 mg, and B vitamins dexpanthenol 4.5 g, nicotinamide 15 mg, thiamine 2 mg, and pyridoxine 1 mg, per 5 mL of syrup. The drug is unregulated in the United States and marketed for selective weight gain. CASE Statement A 40-year-old previously healthy woman was found to have elevated transaminases on pre-employment laboratory work. Outpatient workup revealed elevated smooth muscle mass antibody and unfavorable viral hepatitis serology. She was admitted to the hospital, where she complained of fatigue, right-sided abdominal pain, and jaundice of a few weeks. Her history was significant for alcohol consumption of 2C3 drinks 3 nights per week. She denied taking prescription medications but reported taking an over-the counter-supplement called Apetamin (cyproheptadine, lysine, and vitamin syrup). She started taking the product 6 weeks before to enhance her physique. She revealed that she consumed Enalaprilat dihydrate more than the 5 mL recommended daily dose and instead drank from your bottle to maximize effects. She learned of the drug on social media, where it was promoted as a nonsurgical body augmentation alternative. Laboratory work on presentation was significant for aspartate aminotransferase (AST) 838 U/L, alanine transaminase (ALT) Enalaprilat dihydrate 997 U/L, and alkaline phosphate 90 U/L. Clean muscle mass antibody was 5 occasions the upper limit of normal and IgG 2 times the upper limit of normal (3,162 mg/dL), concerning for AIH. Viral hepatitis serology was unfavorable for hepatitis A IgM, hepatitis B core IgM, hepatitis B surface antigen, and hepatitis C antibody. Human immunodeficiency viruses, Epstein-Barr virusand Cytomegalovirus, QuantiFERON, and mitochondrial antibody were negative; iron and ceruloplasmin were normal. Right upper quadrant ultrasound showed mild echogenicity of the liver seen with hepatic steatosis, normal portal and hepatic veins, and no biliary dilatation. Percutaneous liver biopsy performed on day 2 of admission showed active hepatitis with increased fibrosis, cholestasis, cholangiolar metaplasia, lymphoplasmacytic inflammation, lobular inflammation, disarray, hepatocyte necrosis, and multinucleated hepatocytes (Physique ?(Figure1).1). The patient scored a 16 around the AIH scale, with a pretreatment likelihood of definite AIH. Around the Roussel Uclaf Causality Assessment Method scale, Enalaprilat dihydrate assessing causality between offending drugs and liver damage, the patient scored 11 indicating highly probable adverse drug reaction.3 Findings indicated DIAIH, and the patient was started on prednisone 40 mg oral daily with rapid improvement in liver function. Open in a separate window Physique 1. The biopsy demonstrates (A) a vitamin growth of portal areas by inflammation, (B) many plasma cells in clusters, scattered eosinophils, and macrophages, (C) lobules indicating hepatocyte damage Enalaprilat dihydrate with rarefied cytoplasm, lobular inflammation, cholestasis, hepatocyte drop out, and (D) a trichrome stain showing increased fibrosis with focal areas of bridging. She was Rabbit Polyclonal to Ku80 discharged after 5 days with down-trending transaminases, counseled to stop Apetamin and alcohol, and prescribed prednisone 40 mg oral daily. At the 1-week discharge follow-up, she reported an increase in energy and denied jaundice, itching, or abdominal pain. Transaminases continued to downtrend to AST.