Inappropriate prescription of several herbal remedies in a patient treated with anticancer drugs: a case of subarachnoid haemorrhage

A 51-year-old woman suddenly developed severe headache and vomiting. At the emergency department, the patient also presented with disorientation to place and date, without side effects. The results of tests such as full blood count, erythrocyte sedimentation rate, prothrombin time, fibrinogen concentration, serum urea and electrolytes, as well as screening for autoimmune diseases (including those for LES), were normal. The patient was a non-smoker, with no history of hypertension, diabetes or vascular problems, neither did she have any relevant family history for neurologic illness or hypercoagulability. A computed tomography (CT) scan performed on emergency revealed a low-density area in the splenium of the corpus callosum and intraventricular haemorrhage. The electroencephalogram (EEG)was normal. The patient presented with a memory deficit and mild aphasia, but no functional motor deficit. Since 1 year she has been under treatment with Tamoxifene and Enantone for breast cancer, and recently used some herbal products and supplements comprising Boswellia serrata, Panax ginseng, Viscum album, bromelain, lactoferrin, melatonin and omega-3 fatty acids, as well as several vitamins and minerals. There are numerous reports in the literature suggesting that several supplements may affect coagulation. Dietary supplements could alter coagulation at various points in the cascade, particularly via platelet aggregation. The effects of some dietary supplements on the coagulation cascade may be due to their ability to lower arachidonic acid levels, responsible for their anti-inflammatory effect. However, natural products with anticoagulant/antiplatelet activity may increase bleeding, especially if used in combination with other substances with similar activities. Discussion of the case is focussed on dietary supplements that have been reported to alter haemostasis in humans, such as ginseng, Boswellia, melatonin, bromelain, beta-carotene, vitamins E, C and D and omega-3 fatty acids.