P2894 - Anabolic Steroid-Induced Cholestatic Liver Injury

Osama Qasim Agha, MD¹, Mustafa Alani, MD², Zaid Ansari, MD³, Shehroz Aslam, MD³, Justin Reynolds, MD^1
1St. Joseph's Hospital and Medical Center, Creighton University School of Medicine, Phoenix, AZ; ²Creighton University/St. Joseph's Medical Center, Phoenix, AZ; ³Creighton University School of Medicine, Phoenix, AZ

Introduction: Anabolic-androgenic steroids (AAS) are synthetic compounds that resemble the male hormone testosterone and have an anabolic and masculinizing effect. AAS are sometimes used by bodybuilders and young athletes to increase muscle size and strength. Here, we report a case of drug-induced liver injury (DILI) due to the illicit use of AAS.

Case Description/Methods: A 27-year-old male presented with persistent jaundice and itching for a one-month duration. He had no chronic medical problems and he denied taking any prescribed medications. He had been injecting anabolic androgenic steroids (Nandrolone) intramuscularly once weekly for one year plus taking oral testosterone. He denied any alcohol abuse or IV drug use. His physical exam was only remarkable for scleral icterus and jaundice. His labs were significant for bilirubin 11.4 mg/dl, direct bilirubin 8.4 mg/dl, ALT 52 U/L, AST 47 U/L, and ALP 190 U/L (Table 1). CBC, INR, acute viral hepatitis panel, ANA, AMA, Anti Actin ab, ceruloplasmin levels were all within normal limits. Abdominal ultrasound and MRI were remarkable for a likely benign hemangioma with no cholelithiasis or other acute abnormalities. A liver biopsy showed cholestatic hepatitis with mild inflammatory activity (Figure 1A). A diagnosis of anabolic steroids drug-induced liver injury was made. The patient was counseled about the importance of cessation of all anabolic steroids and he was prescribed ursodiol and hydroxyzine for symptom control. His follow-up labs in one month showed a marked improvement in his labs with near normalization of his bilirubin level (Figures 1B&1C).

Discussion: AAS can be associated with four distinctive forms of liver injury: a transient increase in serum liver enzymes, acute cholestatic injury, chronic vascular injury, and hepatic tumors. Most of these side effects have been linked with the C-17α alkylated form of testosterone.

Patients with acute cholestatic liver injury usually present with jaundice, pruritus, nausea, and fatigue. Bilirubin is usually significantly elevated. ALT is usually mildly elevated but it can be significantly elevated at the beginning of the injury. “Bland cholestasis” associated with minimal or mild inflammation is usually seen on liver biopsy (Figure 1A). The prognosis is excellent with the cessation of the AAS although recovery might be prolonged.


Figure: Figure 1A: Cholestatic hepatitis with mild inflammatory activity. Single arrows: foci of lobular inflammation, double arrows: a minimally inflamed portal tract, square: an area with centrilobular/zone 3 cholestasis with hepatocellular bile accumulation and canalicular bile plugs.
Figure 1B: Trend in bilirubin and direct bilirubin
Figure 1C: Trend in AST, ALT and ALP

Lab	One month prior to presentation	At the time of presentation	One month follow-up	Normal Range
Tbili	4.4 mg/dl	11.4 mg/dl	1.4 mg/dl	0-1.2 mg/dl
Dbili	N/A	8.4 mg/dl	0.64 mg/dl	0-0.5 mg/dl
ALT	663 U/L	52 U/L	94 U/L	6-44 U/L
AST	140 U/L	47 U/L	57 U/L	5-34 U/L
ALP	103 U/L	190 U/L	106 U/L	40-150 U/L

Table: Liver function tests one month prior to presentation, at the time of presentation, and at one-month outpatient follow-up. Tbili: total bilirubin, Dbili: direct bilirubin, ALT: alanine transaminase, AST: aspartate aminotransferase, ALP: alkaline phosphatase, N/A: not available


Disclosures:
Osama Qasim Agha indicated no relevant financial relationships.
Mustafa Alani indicated no relevant financial relationships.
Zaid Ansari indicated no relevant financial relationships.
Shehroz Aslam indicated no relevant financial relationships.
Justin Reynolds: Abbvie – Consultant, Speaker's Bureau.


Osama Qasim Agha, MD¹, Mustafa Alani, MD², Zaid Ansari, MD³, Shehroz Aslam, MD³, Justin Reynolds, MD¹. P2894 - Anabolic Steroid-Induced Cholestatic Liver Injury, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.