Etiology-Based Comparative Evaluation of Toxic Hepatitis in a Tertiary Referral Cohort: Drug-Induced, Herb-Induced, Mushroom Poisoning, and Other Toxic Exposures.

Background and Objectives: Toxic hepatitis may result from drugs, herbal products, mushroom exposure, or other suspected toxic agents. This study aimed to compare the clinical, laboratory, severity-related, and outcome characteristics of toxic hepatitis according to suspected etiology. Materials and Methods: This retrospective observational study included 175 patients diagnosed with toxic hepatitis between January 2012 and March 2026 at a tertiary referral center with an active liver transplantation program. Patients were categorized into five groups: drug-induced liver injury (DILI) (n = 97), herb-induced liver injury (HILI) (n = 17), mushroom poisoning (n = 24), suspected causative agent exposure (n = 15), and unavailable etiological data (n = 22). Clinical outcomes, laboratory parameters, injury patterns, severity grades, and MELD-Na scores were analyzed. Results: Etiological groups differed significantly in demographic, hematological, biochemical, coagulation, bilirubin, ammonia, MELD-Na, and R-ratio parameters. Mushroom poisoning showed the most pronounced hepatocellular injury profile, with higher median values for AST, ALT, INR, ammonia, MELD-Na, and R ratio: 4856 U/L, 4996 U/L, 5.0, 585 µg/dL, 30, and 78.3, respectively. Recovery was most frequent in the HILI group (94.1%). In multivariable logistic regression analysis, older age (OR = 1.066, 95% CI: 1.03-1.11), lower INR (OR = 0.205, 95% CI: 0.08-0.51), and higher albumin level (OR = 4.255, 95% CI: 1.55-11.63) were independently associated with recovery. Conclusions: Toxic hepatitis showed distinct clinical and biochemical patterns according to etiology. In this selected tertiary referral-center cohort, mushroom poisoning was associated with pronounced hepatocellular injury and frequent liver transplantation, whereas HILI showed a more favorable short-term course. These findings should be interpreted in light of referral bias and the overrepresentation of severe cases.