Esterified Anabolic Androgen-Induced Liver Injury in a Hepatitis C Virus-Positive Patient: A CaseReport

Kyrillus S Shohdy,Rasmia M El Gohary

doi:10.5195/ijms.2015.136

Abstract

Background: Cases of drug induced liver injury still perplex gastroenterologists due to its wide range of presentations that mimic acute and chronic liver conditions. Moreover, matters get complicated when clinicians face the possibility of drug-induced injury in the presence of pre-existing chronic liver disease. Case: A 69 year-old male who was recently discovered to have a hepatitis C viral infection presented with acute manifestations (mixed cholangio-hepatocellular injury) not fully explained by the underlying chronic disease, we suspected an idiosyncratic reaction from an esterified anabolic androgen. His manifestations have appeared acutely after the drug intake and include acute onset of jaundice, abdominal pain, pruritus and choluria. He was improving on drug discontinuity and conservative measures during his brief hospital stay. Conclusion: The underlying chronic disease constitutes a dilemma in diagnosis of superimposed drug-induced liver injury, as the proof of causality is a daunting task. In such cases, it is tempting to link such new emerging manifestations to be a flare-up of the underlying chronic disease rather than to the drug. However, certain clues helped to point this clinical presentation towards a drug-induced liver injury

Highlights

Cases of drug induced liver injury (DILI) still perplex gastroenterologists due to its wide range of presentations that mimic acute and chronic liver conditions
Suspicion for DILI with a rarely reported substance may be unlikely in the presence of an underlying chronic liver disease such as hepatitis C virus (HCV) infection
In the review of the literature, we found two cases that developed liver toxicity while using esterified testosterone,[14,15] and one case that developed a hepatic adenoma.[16]

Summary

Introduction

Cases of drug induced liver injury (DILI) still perplex gastroenterologists due to its wide range of presentations that mimic acute and chronic liver conditions. The liver is the most common organ prone to toxicity. The absence of internationally accepted diagnostic criteria for DILI along with underreporting and underrecognition make the overall incidence variable which ranges from 1 in 10,000 to 1 in 100,000 patients.[1,2] For instance, in one population-based cohort study, the incidence was 14 cases in 100,000.3 It is worth noting that hepatotoxicity was found to be the most common cause behind drug withdrawal or drug usage modification.[2]. Suspicion for DILI with a rarely reported substance may be unlikely in the presence of an underlying chronic liver disease such as hepatitis C virus (HCV) infection. Studies that assess the effect of HCV on the progression of DILI in cases of non-acetaminophen toxicity like anabolic steroids are limited in number. The important risk factors for the progression of DILI are age (>55 years old), pregnancy and chronic alcohol consumption,[4] diabetes mellitus is a controversial risk factor.[5,6]

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