Naturopathy and naturopaths are a fairly frequent topic on this blog—and for very good reason. If there is an example of a pseudomedical “discipline” that has been gaining undeserved “respectability,” it’s naturopathy. It’s licensed in all too many states, and physicians who have fallen under the spell of so-called “integrative medicine,” a specialty that rebrands science-based lifestyle medical interventions as somehow “alternative” or “integrative” and uses them as a vessel to “integrate” quackery into medicine, seem to have a special affinity for naturopaths. Indeed, so common has the presence of naturopaths become in academic integrative medicine programs that I’m more surprised when I don’t see one in a program than when I do. Sadly, even my medical alma mater, the University of Michigan, has a prominent “academic naturopath” (an oxymoron if ever there was one) on faculty, and the Society of Integrative Oncology has had not just one, but two, naturopaths as its president in recent years. Basically, doctors, particularly integrative medicine physicians with an MD, have pretty much zero clue what a cornucopia of vitalistic, mystical, pseudoscientific nonsense the vast majority of naturopathy is. The rest (diet, exercise, lifestyle) is nothing unique to naturopathy or anything for which naturopathy is required. Basically, to paraphrase the great Harriet Hall, what is good about naturopathy is not unique, and what is unique about it is not good.
That’s why I periodically like to remind my fellow physicians what naturopathy really is. One way to do that is to point out the sorts of dangerous and unscientific practices embraced by many naturopaths. I saw just such an example earlier this week in, of all places, Ars Technica, in the form of an a story about a case report of a patient poisoned by a naturopath. How that naturopath accomplished the poisoning is something I hadn’t heard of before, making this a two-fer, a reminder of naturopathic quackery and something new that I don’t recall having seen before. I particularly like the title, Naturopath teaches real doctors something—a new way to cause liver damage. The case report tells the tale, Severe liver injury due to Epsom salt naturopathy. Of course, ccase reports are not in and of themselves necessarily indicative of a trend, but in this case, when taken in context with all the other things naturopaths do and the harm they can cause, this particular case report is a cautionary tale.
Epsom salt is basically magnesium sulfate, and Epsom salt solutions have long been used for a number of purposes. In this case a naturopath was using Epsom salt to dissolve gallstones:
A 38-year-old non-alcoholic, non-diabetic man with gallstone disease was prescribed three tablespoons of Epsom salt (magnesium sulfate crystals) with lukewarm water for 15 days for ‘stone dissolution’ by a naturopathy practitioner.
There is, of course, no evidence that magnesium sulfate can dissolve gallstones. Indeed, even compounds known to be able to dissolve stones, like ursodeoxycholic acid tablets, don’t work very well and are almost never used. Basically, channeling my old general surgery knowledge, I know that asymptomatic gallstones are usually left alone. When they become symptomatic, that is usually an indication for surgery to remove the gallbladder, particularly if the patient develops acute cholecystitis or other complications of gallstone disease. Basically, gallstone disease is a surgical disease, to be watched if asymptomatic and operated on if it becomes symptomatic or causes complications.
The man treated by this naturopath did not do well:
He developed loss of appetite and darkening of urine from the 12th day on treatment and jaundice from the second day after treatment completion. The patient denied fevers, skin rash, joint pains, myalgia, abdominal pain, abdominal distension and cholestatic symptoms. Examination revealed a deeply icteric patient oriented to time, place and person without organomegaly or stigmata of chronic liver disease.
Jaundice, of course, is an indication of liver dysfunction, which can be due to obstruction of the biliary system or damage to the liver tissue itself (hepatocellular injury). Darkening of the urine is a sequelae of the elevated bilirubin levels in the blood that result in jaundice. The patient’s blood chemistry values were consistent with hepatocellular injury as a cause of his jaundice. These lab values, however, are nonspecific and can only tell us that there is liver cell injury, not the cause. That required further tests:
Tests for viral hepatitis A, E, B, C, cytomegalovirus, Epstein-Barr and herpes simplex viruses and those for autoimmune hepatitis and IgG4 disease were unremarkable. There was no evidence of underlying sepsis and other organ failures. Contrast enhanced CT of upper abdomen revealed only hepatomegaly with mild periportal oedema. Percutaneous liver biopsy revealed submassive necrosis with dense portal-based fibrosis, mixed portal inflammation, extensive perivenular canalicular and hepatocellular cholestasis with macrovesicular steatosis and perisinusoidal fibrosis (suggestive of steatohepatitis) without evidence of granulomas, inclusion bodies or vascular changes suggestive of acute drug-induced liver injury (figure 1). Polarising microscopy did not reveal crystalline deposits.
Translation: There was no evidence for viral infection or autoimmune hepatitis, nor was there evidence of sepsis. The liver was enlarged. The biopsy revealed “submassive” death of liver tissue with inflammation and scarring. This resulted in cholestasis, the stasis of bilirubin in the biliary system. Steatohepatitis is hepatitis associated with fatty infiltration of the liver, often a sign of liver injury. (Alcohol, for instance, can cause the same fatty infiltration of the liver with inflammation, albeit usually much more chronically.) In other words, this man’s liver was messed up.
Fortunately, the liver is an incredibly resilient organ. Cessation of Epsom salt intake resulted in the man’s recovery, with his lab values returning to normal in 38 days. The authors note that Epsom salt overuse can cause diarrhea, electrolyte abnormalities, kidney injury, and cardiac arrhythmias. However, it can also cause liver injury:
Liu et al described the patterns of mineral-associated hepatic injury due to inhalational or intravenous exposure with pure silica, chromium-cobalt alloy and magnesium silicate (talc) in seven patients.3 They demonstrated that silica led to formation of sclerohyaline nodules within portal tracts and lobules in contrast to magnesium silicate injury that was associated with a predominant reactive fibrosis in portal and centrilobular areas. These patients were chronically exposed, in contrast to our patient who consumed Epsom salt in large quantities within a short period of time leading to predominantly necrotic and dense reactive fibrotic type of injury. Epsom salt-related severe liver injury and its histopathology have not been described in literature before. The Roussel Uclaf Causality Assessment Method (RUCAM) score was strongly suggestive of Epsom salt injury in our patient. We believe that underlying non-alcoholic steatohepatitis potentiated extensive liver injury in our patient, which resolved on stopping the offending agent.
Basically, the authors are explaining that what was observed in this patient was different from what is usually observed in patients with toxicity due to magnesium salts in that usually such toxicity is chronic, which results in fibrosis or scarring. In this case, the toxicity was acute and resulted in the death of significant swaths of liver tissue. Now, I will admit that I was not familiar with the Roussel Uclaf Causality Assessment Method (RUCAM) for liver injury. So I looked it up. It turns out that it’s a system for assessing the likelihood that a given drug is the cause of acute liver injury observed. Points are awarded for seven components:
- Time to onset of the injury following start of the drug
- Subsequent course of the injury after stopping the drug
- Specific risk factors (age, alcohol use, pregnancy)
- Use of other medications with a potential for liver injury
- Exclusion of other causes of liver disease
- Known potential for hepatotoxicity of the implicated drug
- Response to rechallenge
Total scores range from less than 0 to 14 with scores below 3 indicating unlikely, 4-5 possible, 6-8 probable, and >8 highly probable hepatotoxicity. The scale isn’t that commonly used, because interpretation of some of its components can be a bit subjective, but it is useful for suggesting drug-caused liver toxicity, and clearly this patient had enough positives in his RUCAM assessment for his liver was highly suggestive that the injury was due to Epsom salt. Also, normally, when Epsom salt is used as a laxative, it’s recommended that patients take 10-30 g in at least 250 ml water. This man was taking 45 g every day.
Edzard Ernst noted that this isn’t the only serious adverse event that can occur as a result of excessive Epsom salt use. For instance, there is a case report of a fatality from hypermagnesemia (elevated blood magnesium levels) due to an Epsom salt enema administered to a 7 year old. Yes, a 7 year old.
Basically, naturopaths have advocated Epsom salt to “dissolve” gallstones for a very, very long time, even though there is no evidence that they are efficacious for this purpose. Whenever someone asks, “What’s the harm?” I can answer: Right here. Whenever considering alternative treatments like this, it’s important to remember that even benign substances (like Epsom salt) can be dangerous if used to excess. Unfortunately, all too often naturopaths think that, if a little is good (or at least harmless), then a lot will be better, and a hell of a lot better still. That’s a major part of the philosophy of naturopaths, if you leave out homeopathy, and that’s how you fry someone’s liver with something as seemingly benign as Epsom salt.