BA JIAO LIAN
Ba Jiao Lian is an herb derived from Dysosma pleianthus, a species of mayapple found in China, which has been used for thousands of years in Chinese medicine. Ba Jian Lian has been implicated in a generalized toxicity marked by nausea, abdominal pain, bone marrow suppression, confusion and accompanying liver injury.
Ba Jiao Lian has been used in Chinese medicine for centuries as a general remedy and for treatment of weakness, venereal disease, tumors and snakebite. Similarly, Native Americans often used the root extracts of the indigenous North American mayapple plant (podophyllum peltatum) as a laxative and for other disorders. Ba Jiao Lian has been implicated in a generalized toxicity marked by gastrointestinal, bone marrow, neurological and hepatic injury, which is believed to be due to podophyllum, a major ingredient in the herb. Podophyllum comprises several glycosides, the most toxic of which is podophyllotoxin. Podophyllum is also used in Western medicine topically to treat warts, and chemical modifications of podophyllotoxin have been developed as anticancer agents (etoposide and teniposide). While it was used for centuries in traditional Chinese medicine, Ba Jiao Lian is inherently toxic and, when taken in high enough doses, causes a distinctive clinical syndrome of nausea, diarrhea and vomiting followed by confusion, stupor, and coma with fever, leukocytosis, thrombocytopenia, abnormal liver tests and sensory-motor and autonomic neuropathy.
Ba Jiao Lian causes a toxic syndrome that includes abnormal liver tests, although the other symptoms overshadow the liver injury and most patients have not developed jaundice or hepatic failure. In cases of intoxication reported from Asia, patients have had minimal elevations (1 to 3 times the upper limit of the normal range) in serum aminotransferase levels, with AST usually higher than ALT and no jaundice. Indeed, muscle and other organ injury may account for some of the serum enzyme elevations in Ba Jiao Lian toxicity.
Mechanism of Injury
The mechanism of hepatotoxicity of Ba Jiao Lian is likely due to podophyllotoxin, which is contained in variable concentrations in the (unripe) fruit, foliage, stems and roots of the mayapple plant. The podophyllum glycosides are directly toxic to cells.
Outcome and Management
Hepatotoxicity from Ba Jiao Lian is mild and greatly overshadowed by its gastrointestinal, bone marrow and neurologic toxicity.
REPRESENTATIVE TRADE NAMES
Ba Jiao Lian – Generic
Herbal and Dietary Supplements
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References updated: 05 September 2017
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Navarro VJ, Barnhart H, Bonkovsky HL, Davern T, Fontana RJ, Grant L, Reddy KR, et al. Liver injury from herbals and dietary supplements in the U.S. Drug-Induced Liver Injury Network. Hepatology 2014; 60:1399-408. PubMed Citation (Among 130 cases of HDS associated liver injury enrolled in a US prospective study between 2004 and 2013, none were attributed to Ba Jiao Lian).
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