Atypical Presentation of Adrenocortical Insufficiency with Anorexia and Jaundice

Mild liver injury following withdrawal of long-term prednisone therapy: A case report

BACKGROUND

Liver injury manifesting as hepatic enzyme abnormalities, has been occasionally identified to be a feature of primary or secondary Addison's disease, an uncommon endocrine disease characterized by adrenal insufficiency. There have been no more than 30 reported cases of liver injury explicitly attributed to Addison's disease. Liver injury resulting from adrenal insufficiency due to glucocorticoid withdrawal is exceptionally rarer.

CASE SUMMARY

A 42-year-old man presented with fatigue and mildly elevated transaminases. Laboratory investigations and imaging studies excluded common etiologies of liver injury. Based on the fact that the patient discontinued long-term therapy with prednisone approximately 2 weeks before he was found to have elevated transaminase levels and the observation that his cortisol was lower than the normal value, he was diagnosed as having hypertransaminasemia secondary to adrenal insufficiency caused by glucocorticoid withdrawal. The patient was infused intravenously with compound diisopropylamine dichloroacctate and compound glycyrrhizin, and his transaminase levels returned to normal after 1 week. Approximately 2 years later, the patient received hydroprednisone treatment for 2 days in an endoscopic sinus surgery. Eight days after he discontinued the hydroprednisone treatment, he developed symptoms reminiscent of glucocorticoid withdrawal syndrome. These symptoms resolved spontaneously after 1 week. Intriguingly, the patient did not develop hepatic dysfunction this time.

CONCLUSION

The present case, showing some unusual clinical features, highlights the importance of education of clinicians and patients to avoid improper discontinuation of glucocorticoid therapy and complete history taking for prompt recognition.