Anabolic Steroid Induced Cholestasis Secondary to a Dietary Supplement

Abstract

Dietary supplement consumption has become increasingly popular over the last decade, both through internet sales and retail stores globally. Although the U.S Food and Drug Administration (FDA) prohibits the marketing of synthetic compounds as dietary supplements, the agency has limited role in the enforcement of safety testing, marketing, and regulation of health food supplements. We present a case of prolonged drug-induced jaundice resulting from the use of a body-building supplement that was purchased from a local nutrition store. Case report: A previously healthy 22-year-old Caucasian man presented with a two- week history of progressive jaundice, dark urine, and pruritus. He had no risk factors for viral hepatitis and he did not abuse alcohol. Physical exam showed a well developed and deeply jaundiced young man without hepatomegaly. Laboratory studies showed AST/ALT, 57/91 U/L, alkaline phosphatase, 203 U/L, total bilirubin, 33 mg/dL, albumin, 4.7 g/dL, INR, 0.99. Viral hepatitis serologies were negative and ceruloplasmin was normal. Abdominal ultrasound showed a normal liver without biliary dilatation. Over the next 11 weeks, his symptoms abated and the jaundice resolved. Additional questioning revealed that he started taking an over-the-counter muscle building supplement (Anabolic Xtreme Superdrol® one tablet daily) four weeks before the onset of jaundice. The active ingredient of this compound is 2a-17a-dimethyl-5a-androst-3-one. Discussion: Anabolic steroid induced cholestasis has been well documented. All of these steroids are synthetic agents with an alkyl group in the C17 position, including the product in this case. The distribution/sale of a presumed dietary supplement that was later revealed as a known hepatotoxin represented an FDA regulatory violation. On March 8, 2006, the FDA sent a letter to the product manufacturer (http://www.fda.gov/foi/warning_letters/g5736d.pdf) ordering the discontinuation of further interstate commerce involving this product. Given the widespread distribution of this compound, clinicians should be aware that a dietary supplement whose active ingredient contains an anabolic steroid may remain in circulation and may cause protracted cholestasis.