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Rhabdomyolysis Caused by Commiphora mukul, a Natural Lipid-Lowering Agent

Director, Traditional Medicine Department, Centro di Orientamento Educativo, Barzio, Italy

Paola Cantù, MD

Head, Nephrology Department, Gallarate Hospital, Gallarate, Italy

Fabio Firenzuoli, MD

Phytotherapist, Director, Centre for Natural Medicine, S. Giuseppe Hospital, Empoli, Italy

Gabriela Mazzanti, PhD

Associate Professor, Faculty of Pharmacy, University "La Sapienza," Rome, Italy

Francesca Menniti-Ippolito, MSc

Senior Epidemiologist, National Institute of Health, Rome

Roberto Raschetti, MSc

Senior Epidemiologist, National Institute of Health, Rome

Reprints: Francesca Menniti-Ippolito MSc, Department of Epidemiology, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161 Rome, Italy, fax 39 0649387155, fmenniti{at}iss.it

OBJECTIVE: To report a case of rhabdomyolysis caused by Commiphora mukul, a natural lipid-lowering agent.

CASE SUMMARY: A 55-year-old man was taking an extract of C. mukul 300 mg 3 times daily to lower his cholesterol level. He developed rhabdomyolysis with hemoglobinuria after 2 weeks of treatment. Laboratory tests showed creatine kinase 144 600 IU/L (reference range 24–195), myoglobin >3000 ng/mL (28–72), lactate dehydrogenase 7157 IU/L (230–460), aspartate aminotransferase 1115 IU/L (10–35), and alanine aminotransferase 205 IU/L (10–35). Analysis of a urine sample was 2+ positive for hemoglobin. All parameters returned to normal after the herbal preparation was discontinued.

DISCUSSION: The Naranjo probability scale indicates C. mukul as the possible cause of rhabdomyolysis in our patient. Drug-induced rhabdomyolysis is an established but rare adverse effect of high doses of cholesterol-lowering agents (statins) or interactions between drugs (eg, statins and fibrates). As of May 28, 2004, to our knowledge, this is the first reported case of rhabdomyolysis following C. mukul ingestion.

CONCLUSIONS: Our report describes a case of rhabdomyolysis possibly caused by C. mukul and underlines the need for active surveillance of natural products.

Key Words: Commiphora mukul, guggul, herbal supplements, rhabdomyolysis

Published Online, June 8, 2004. www.theannals.com, DOI 10.1345/aph.1D486

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