Esterified Anabolic Androgen-Induced Liver Injury in a Hepatitis C Virus-Positive Patient: A CaseReport
Keywords:Drug-Induced Liver Injury, Hepatitis; Steroids, Biological Markers
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
2. Devarbhavi H. An update on drug-induced liver injury. J Clin Exp Hepatol. 2012 Sep; 2(3): 247-59.
3. Sgro C, Clinard F, Ouazir K, Chanay H, Allard C, Guilleminet C, et al. Inci¬dence of drug-induced hepatic injuries: a French population-based study. Hepatology. 2002 Aug;36(2):451-5.
4. Danan G, Benichou C. Causality assessment of adverse reactions to drugs—I. A novel method based on the conclusions of international consen¬sus meetings: application to drug-induced liver injuries. J Clin Epidemiol. 1993 Nov;46(11):1323-30.
5. Chalasani N, Fontana RJ, Bonkovsky HL, Watkins PB, Davern T, Serrano J, et al. Causes, clinical features, and outcomes from a prospective study of drug-induced liver injury in the United States. Gastroenterology. 2008 Dec;135(6):1924-34, 1934.e1-4.
6. Andrade RJ, Lucena MI, Fernández MC, Pelaez G, Pachkoria K, García-Ruiz E, et al. Drug-induced liver injury: an analysis of 461 incidences submit¬ted to the Spanish registry over a 10-year period. Gastroenterology. 2005 Aug;129(2):512-21.
7. Synder P. Androgens. In: Brunton L, Chabner B, Knollman B, editors. Good¬man & Gilman’s the pharmacological basis of therapeutics. 12th ed. New York: McGraw-Hill; 2011. p. 1195-208.
8. Marquardt GH, Logan CE, Tomhave WG, Dowben RM. Failure of non-17- alkylated anabolic steroids to produce abnormal liver function tests. J Clin Endocrinol Metab. 1964 Dec;24:1334-6.
9. Nguyen GC, Sam J, Thuluvath PJ. Hepatitis C is a predictor of acute liver injury among hospitalizations for acetaminophen overdose in the United Sta¬tes: a nationwide analysis. Hepatology. 2008 Oct;48(4):1336-41.
10. Chalasani NP, Hayashi PH, Bonkovsky HL, Navarro VJ, Lee WM, Fontana RJ; Practice Parameters Committee of the American College of Gastroentero¬logy. ACG Clinical Guideline: the diagnosis and management of idiosyncratic drug-induced liver injury. Am J Gastroenterol. 2014 Jul;109(7):950-66; quiz 967.
11. Watkins PB, Seeff LB. Drug-induced liver injury: summary of a single topic clinical research conference. Hepatology. 2006 Mar;43(3):618-31.
12. Huang Y-S. S1881 the therapeutic efficacy of ursodeoxycholic acid (UDCA) in drug-induced liver injury: results of a randomized controlled trial. Gas-troenterology. 2010 May;138(5):S–809.
13. Kaplowitz N. Drug-induced liver disease. 3rd ed. Philadelphia: Elsevier Inc; 2013. p. 3-14.
14. Yoshida EM, Erb SR, Scudamore CH, Owen DA. Severe cholestasis and jaundice secondary to an esterified testosterone, a non-C17 alkylated anabo¬lic steroid. J Clin Gastroenterol. 1994 Apr;18(3):268-70.
15. Savvidou S, Gagalis A, Efstratiou I, Kalambakas A. Anabolic androgen-in¬duced intrahepatic cholestasis presented with normal ?-glutamyl-transpepti¬dase. J Interdiscipl Histopathol. 2014;2(2):98-103.
16. Carrasco D, Prieto M, Pallardó L, Moll JL, Cruz JM, Muñoz C, et al. Multiple hepatic adenomas after long-term therapy with testosterone enanthate. Re¬view of the literature. J Hepatol. 1985;1(6):573-8.
17. Tyagi A, Rajalakshmi M, Jeyaraj DA, Sharma RS, Bajaj JS. Effects of long-term use of testosterone enanthate. II. Effects on lipids, high and low den¬sity lipoprotein cholesterol and liver function parameters. Int J Androl. 1999 Dec;22(6):347-55.
18. García-Cortés M, Stephens C, Lucena MI, Fernández-Castañer A, Andrade RJ; Spanish Group for the Study of Drug-Induced Liver Disease (Grupo de Estudio para las Hepatopatías Asociadas a Medicamentos GEHAM). Causality assessment methods in drug induced liver injury: strengths and weaknes¬ses. J Hepatol. 2011 Sep;55(3):683-91.
19. Liss G, Rattan S, Lewis JH. Predicting and preventing acute drug-indu¬ced liver injury: what's new in 2010? Expert Opin Drug Metab Toxicol. 2010 Sep;6(9):1047-61.
20. Daly AK, Donaldson PT, Bhatnagar P, Shen Y, Pe'er I, Floratos A, et al. HLA-B*5701 genotype is a major determinant of drug-induced liver injury due to flucloxacillin. Nat Genet. 2009 Jul;41(7):816-9.
How to Cite
Authors who publish with this journal agree to the following terms:
- The Author retains copyright in the Work, where the term “Work” shall include all digital objects that may result in subsequent electronic publication or distribution.
- Upon acceptance of the Work, the author shall grant to the Publisher the right of first publication of the Work.
- The Author shall grant to the Publisher and its agents the nonexclusive perpetual right and license to publish, archive, and make accessible the Work in whole or in part in all forms of media now or hereafter known under a Creative Commons Attribution 4.0 International License or its equivalent, which, for the avoidance of doubt, allows others to copy, distribute, and transmit the Work under the following conditions:
- Attribution—other users must attribute the Work in the manner specified by the author as indicated on the journal Web site; with the understanding that the above condition can be waived with permission from the Author and that where the Work or any of its elements is in the public domain under applicable law, that status is in no way affected by the license.
- The Author is able to enter into separate, additional contractual arrangements for the nonexclusive distribution of the journal's published version of the Work (e.g., post it to an institutional repository or publish it in a book), as long as there is provided in the document an acknowledgment of its initial publication in this journal.
- Authors are permitted and encouraged to post online a prepublication manuscript (but not the Publisher’s final formatted PDF version of the Work) in institutional repositories or on their Websites prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work. Any such posting made before acceptance and publication of the Work shall be updated upon publication to include a reference to the Publisher-assigned DOI (Digital Object Identifier) and a link to the online abstract for the final published Work in the Journal.
- Upon Publisher’s request, the Author agrees to furnish promptly to Publisher, at the Author’s own expense, written evidence of the permissions, licenses, and consents for use of third-party material included within the Work, except as determined by Publisher to be covered by the principles of Fair Use.
- The Author represents and warrants that:
- the Work is the Author’s original work;
- the Author has not transferred, and will not transfer, exclusive rights in the Work to any third party;
- the Work is not pending review or under consideration by another publisher;
- the Work has not previously been published;
- the Work contains no misrepresentation or infringement of the Work or property of other authors or third parties; and
- the Work contains no libel, invasion of privacy, or other unlawful matter.
- The Author agrees to indemnify and hold Publisher harmless from the Author’s breach of the representations and warranties contained in Paragraph 6 above, as well as any claim or proceeding relating to Publisher’s use and publication of any content contained in the Work, including third-party content.
Enforcement of copyright
The IJMS takes the protection of copyright very seriously.
If the IJMS discovers that you have used its copyright materials in contravention of the license above, the IJMS may bring legal proceedings against you seeking reparation and an injunction to stop you using those materials. You could also be ordered to pay legal costs.
If you become aware of any use of the IJMS' copyright materials that contravenes or may contravene the license above, please report this by email to email@example.com
If you become aware of any material on the website that you believe infringes your or any other person's copyright, please report this by email to firstname.lastname@example.org