Drug-induced liver injury (DILI) is the leading cause of acute liver failure, presenting with various manifestations such as hepatitis, cholestasis, steatosis, or overlapping changes [1]. Most patients with DILI could gradually recover once the causative drug is discontinued [2]. However, studies have revealed that approximately 10 % of those with acute DILI and jaundice face an increased risk of mortality or the need for liver transplantation [3]. Despite its clinical significance, diagnosing DILI remains challenging. In recent years, the Roussel Uclaf Causality Assessment Method (RUCAM) has emerged as a widely used tool for evaluating DILI cases [4,5]. However, RUCAM lacks the ability to differentiate between causative agents in cases where multiple drugs are involved in the combination therapy [6]. The development of sensitive and specific indicators that can distinguish between these causes is crucial for improving diagnostic accuracy and exploring targeted therapies for DILI.

Scutellaria baicalensis (SB), known as Huangqin in Chinese, is one of the most widely utilized herbal medicines [7]. SB is extensively used in various medical applications, including diarrhea, respiratory infections, and severe acute respiratory syndrome coronavirus 2 [4,8,9]. Nevertheless, despite its rarity, the reports of SB-induced liver injury (SB-DILI) have consistently raised some concerns [5,6]. A comprehensive understanding of SB-DILI is needed to improve its prevention, diagnosis, and treatment. Especially, the lack of specific diagnostic indicators makes SB-DILI diagnosis ambiguous when SB is used with other drugs. Antibiotics, widely used globally, are a leading cause of DILI [10]. As antibiotics are frequently combined with SB in therapeutic regimens, cases of liver injury have occasionally been reported [11,12]. However, differentiating between SB-DILI and antibiotic-induced DILI (AILI) presents a significant diagnostic challenge [13].

Microvesicles (MVs) are extracellular vesicles released by cells, which exert regulatory roles in various pathophysiological processes of multiple liver diseases [14,15]. Numerous studies have shown that proteins carried by MVs serve as valuable indicators for the diagnosis of several conditions, including liver diseases, cardiometabolic diseases, and cancer [[16], [17], [18]]. Nevertheless, identifying specific indicators for the detection and diagnosis of DILI remains a challenge.

To identify potential diagnostic indicators capable of distinguishing between SB-DILI and AILI, we employed a mass spectrometry-based workflow. This approach utilized a label-free quantitative proteomics strategy by LC-MS/MS for indicator discovery and parallel reaction monitoring (PRM) to validate key indicators in two longitudinal cohorts [19]. Our study thoroughly analyzed the serum MV proteomes of patients with SB-DILI and AILI, identifying distinct indicators that can facilitate accurate classification between the two conditions.