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A Case Report about Glycogenic Hepatopathy. Case Rep Endocrinol 2022; 2022:5134049. [PMID: 36304180 PMCID: PMC9596235 DOI: 10.1155/2022/5134049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 09/19/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Glycogenic hepatopathy is a rare complication of uncontrolled diabetes mellitus that presents with hepatomegaly and transient elevation in serum aminotransferase enzymes. The underlying pathophysiology involves excessive accumulation of intrahepatic glycogen. Glycogenic hepatopathy is usually underdiagnosed because it is difficult to differentiate from other entities, such as the nonalcoholic fatty liver. The gold standard for diagnosis is liver biopsy. Glycogenic hepatopathy can be reversed by the achievement of adequate glycemic control. Case description. A 19-year-old female patient with a history of poorly controlled type 1 diabetes mellitus that resulted in several episodes of diabetes ketoacidosis requiring hospital admissions. The patient presented to the emergency room with generalized weakness and fatigue found to have diabetic ketoacidosis. Blood tests revealed abnormal liver function with aspartate aminotransferase 1129 U/L (13–37 U/L), alanine aminotransferase 766 U/L (13–56 U/L), alkaline phosphatase 216 U/L (45–117 U/L), total bilirubin 1.0 mg/dL (0.2–1.3 mg/dL), albumin 3.8 g/dL (3.4–5.0 g/dL), partial thromboplastin time < 20 s (23–31 s), prothrombin time 11.8 s (9.5–11.5 s), and international normalized ratio 1.1. Acute hepatitis serologies were negative. Epstein–Barr virus and cytomegalovirus were ruled out. Extensive autoimmune hepatitis tests were negative. Primary biliary cirrhosis was also ruled out. A liver biopsy was obtained, which was diagnostic of glycogenic hepatopathy. Conclusion Glycogenic hepatopathy must be suspected in patients with uncontrolled type 1 diabetes mellitus who present with elevated liver enzymes and hepatomegaly. Treating this rare condition requires a timely diagnosis with liver biopsy and strict glycemic control.
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Garcês Soares S, Medas R, Conceição F, Silva R, Paiva JA, Carneiro AC. Hepatic Glycogenosis: An Underdiagnosed Entity? Cureus 2022; 14:e23853. [PMID: 35530830 PMCID: PMC9072257 DOI: 10.7759/cureus.23853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/12/2022] Open
Abstract
Hepatic glycogenosis (HG) is a rare complication of long-standing poorly controlled type 1 diabetes mellitus (T1DM), which is often misdiagnosed as non-alcoholic fatty liver disease (NAFLD). Despite the existence of several reports in the literature, it still is underrecognized, even among gastroenterologists. Differential diagnosis between these entities is essential since they have different prognoses. We report a case of an 18-year-old female, with a medical history of poorly controlled T1DM, admitted to an intensive care unit with severe diabetic ketoacidosis (DKA). Upon admission, aminotransferases were significantly elevated; bilirubin and coagulation tests were normal. Despite adequate DKA treatment, she had persistently elevated aminotransferases and hyperlactacidemia. Imaging studies showed hepatomegaly and bright liver parenchyma. Extensive laboratory workup was negative for other causes of liver disease. So, a liver biopsy was performed, which was consistent with the diagnosis of HG. Under strict metabolic control, she had progressive improvement, achieving biochemical normalization within 6 months. This case highlights the need for clinicians to be aware of this condition due to non-negligible differences between HG and NAFLD, with the latter progressing to fibrosis, and ultimately cirrhosis and hepatocarcinoma. On the opposite, HG is considered a benign condition, associated with an excellent prognosis that can be reversible after adequate metabolic control. Liver biopsy remains the gold standard method for HG diagnosis since it can distinguish it from NAFLD.
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Mertens J, De Block C, Spinhoven M, Driessen A, Francque SM, Kwanten WJ. Hepatopathy Associated With Type 1 Diabetes: Distinguishing Non-alcoholic Fatty Liver Disease From Glycogenic Hepatopathy. Front Pharmacol 2021; 12:768576. [PMID: 34759828 PMCID: PMC8573337 DOI: 10.3389/fphar.2021.768576] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/06/2021] [Indexed: 12/14/2022] Open
Abstract
Autoimmune destruction of pancreatic β-cells results in the permanent loss of insulin production in type 1 diabetes (T1D). The daily necessity to inject exogenous insulin to treat hyperglycemia leads to a relative portal vein insulin deficiency and potentiates hypoglycemia which can induce weight gain, while daily fluctuations of blood sugar levels affect the hepatic glycogen storage and overall metabolic control. These, among others, fundamental characteristics of T1D are associated with the development of two distinct, but in part clinically similar hepatopathies, namely non-alcoholic fatty liver disease (NAFLD) and glycogen hepatopathy (GlyH). Recent studies suggest that NAFLD may be increasingly common in T1D because more people with T1D present with overweight and/or obesity, linked to the metabolic syndrome. GlyH is a rare but underdiagnosed complication hallmarked by extremely brittle metabolic control in, often young, individuals with T1D. Both hepatopathies share clinical similarities, troubling both diagnosis and differentiation. Since NAFLD is increasingly associated with cardiovascular and chronic kidney disease, whereas GlyH is considered self-limiting, awareness and differentiation between both condition is important in clinical care. The exact pathogenesis of both hepatopathies remains obscure, hence licensed pharmaceutical therapy is lacking and general awareness amongst physicians is low. This article aims to review the factors potentially contributing to fatty liver disease or glycogen storage disruption in T1D. It ends with a proposal for clinicians to approach patients with T1D and potential hepatopathy.
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Affiliation(s)
- Jonathan Mertens
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium.,Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Edegem, Belgium.,Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Wilrijk, Belgium
| | - Christophe De Block
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Edegem, Belgium.,Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Wilrijk, Belgium
| | - Maarten Spinhoven
- Department of Radiology, Antwerp University Hospital, Edegem, Belgium
| | - Ann Driessen
- Department of Pathology, Antwerp University Hospital, Antwerp, Belgium.,CORE, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Sven M Francque
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium.,Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Wilrijk, Belgium
| | - Wilhelmus J Kwanten
- Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium.,Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Wilrijk, Belgium
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Touilloux B, Lu H, Campos-Xavier B, Superti-Furga A, Hauschild M, Bouthors T, Tran C. Elevated lactate in Mauriac syndrome: still a mystery. BMC Endocr Disord 2021; 21:172. [PMID: 34419042 PMCID: PMC8379780 DOI: 10.1186/s12902-021-00835-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 08/04/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The Mauriac syndrome was described in 1930 as a peculiar combination of poorly controlled diabetes mellitus type 1, stunted growth and glycogenic hepatopathy. More recently, lactic acidosis was recognized as an additional feature, often induced by insulin treatment. CASE PRESENTATION A 17-year old girl known for diabetes type 1A and Mauriac syndrome was admitted to the emergency room with hyperglycemia of > 41 mmol/l without ketoacidosis. Under a standard insulin regimen, hyperglycemia was rapidly corrected but marked hyperlactatemia occurred. CONCLUSIONS The mechanism of impaired glucose utilization and lactate elevation independent of ketoacidosis in Mauriac syndrome is intriguing. The rarity of Mauriac syndrome and its resemblance to glycogen storage diseases suggest the presence of a specific metabolic or genetic predisposition that remains to be identified.
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Affiliation(s)
- Brice Touilloux
- Center for Molecular Diseases, Division of Genetic Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- Respiratory Medicine Department, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Henri Lu
- Service of Cardiology, Department of Cardio-Vascular Medicine and Surgery, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Belinda Campos-Xavier
- Center for Molecular Diseases, Division of Genetic Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Andrea Superti-Furga
- Center for Molecular Diseases, Division of Genetic Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Michael Hauschild
- Pediatric Endocrinology, Diabetology and Obesity Unit, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Thérèse Bouthors
- Pediatric Endocrinology, Diabetology and Obesity Unit, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Christel Tran
- Center for Molecular Diseases, Division of Genetic Medicine, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland.
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Abu NA, Lim CB, Nor NSM. Glycogenic hepatopathy in children with poorly controlled type 1 diabetes mellitus. Clin Pediatr Endocrinol 2021; 30:93-97. [PMID: 33867669 PMCID: PMC8022034 DOI: 10.1297/cpe.30.93] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/22/2020] [Indexed: 12/11/2022] Open
Abstract
Mauriac syndrome is a rare and underdiagnosed complication of type 1 diabetes mellitus
(T1DM). It is characterized by growth retardation, delayed puberty, Cushingoid features,
hepatomegaly, and increased transaminase levels. The term glycogenic hepatopathy has been
used to describe patients with poorly controlled T1DM and glycogen overload in the
hepatocytes but without all the features of Mauriac syndrome. Although rare, glycogenic
hepatopathy is reported to be the main cause of hepatomegaly in young patients with T1DM.
We report two cases of glycogenic hepatopathy in children with poorly controlled T1DM.
Both children had hepatomegaly, elevated liver enzyme levels, and elevated lactate levels.
A liver biopsy confirmed the diagnosis of glycogenic hepatopathy in both patients. In
conclusion, hepatomegaly with elevated liver enzymes, negative infective and metabolic
screenings and persistently elevated plasma lactate levels should raise the suspicion of
glycogenic hepatopathy in poorly controlled T1DM. Early diagnosis and improvement in
glycemic control are the mainstays of treatment, which can prevent long-term
complications.
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Affiliation(s)
- Nor Azizah Abu
- Department of Pediatric, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Selangor, Malaysia
| | - Chooi Bee Lim
- Department of Pediatric, Selayang Hospital, Ministry of Health, Lebuhraya Kepong Selayang, Selangor, Malaysia
| | - Noor Shafina Mohd Nor
- Department of Pediatric, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Selangor, Malaysia.,Institute for Pathology, Laboratory and Forensic Medicine (I-PPerForM), Universiti Teknologi MARA (UiTM), Selangor, Malaysia
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Abstract
Lactic acidosis results from an acid-base balance disorder of the body due to an excess of lactic acid. It is frequently found in critically ill patients admitted to the intensive care. The most common cause is type A, found in pathologies such as cardiogenic, septic and hypovolemic shock, trauma and severe hypoxemia. The type B is less common and arises without evidence of tissue hypoperfusion or shock. Divers etiologies have been described for this type of hyperlactatemia: Grand Mal seizures, liver failure, hematologic malignancies, congenital enzyme deficiencies, thiamine deficiencies and diabetes mellitus and also alcohol abuse, which may induce a lactic acid under-use or an increased production. The authors describe a rare complication of type 1 Diabetes Mellitus (T1DM), leading to a major and persistent expression of a type B lactic acidosis during ketoacidosis.
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Papazafiropoulou A, Melidonis A. Antidiabetic agents in patients with hepatic impairment. World J Meta-Anal 2019; 7:380-388. [DOI: 10.13105/wjma.v7.i8.380] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/07/2019] [Accepted: 08/20/2019] [Indexed: 02/06/2023] Open
Abstract
Chronic liver disease (CLD) often coexists with type 2 diabetes mellitus, making diabetes management a challenge to the clinician. It is well known that liver is the major site of drug metabolism, and, therefore, its impairment affects hepatic metabolism of many antidiabetic agents. Furthermore, patients with CLD have serious comorbidities such as impaired renal function, hypoalbuminemia, lactic acidosis, hypoglycemia and malnutrition, making their treatment even more difficult. On the other hand, most of the antidiabetic agents, with the exception of insulin, need dosage titration due to alterations to their pharmacokinetics in patients with CLD. For well-established antidiabetic treatments, like metformin and sulfonylureas there are studies regarding their dosage chance in these patients. However, despite the growing problem of management of diabetes in patients with CLD the existing literature data, especially on newer antidiabetic agents, are limited and, furthermore, no direct guidelines exist. Therefore, in the present review article we try to summarize the existing literature data regarding management of diabetes in patients with CLD.
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Affiliation(s)
- Athanasia Papazafiropoulou
- 1st Department of Internal Medicine and Diabetes Center, Tzaneio General Hospital of Piraeus, Athens 18536, Greece
| | - Andreas Melidonis
- 1st Department of Internal Medicine and Diabetes Center, Tzaneio General Hospital of Piraeus, Athens 18536, Greece
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Abstract
Glycogenic hepatopathy is excessive intrahepatic glycogen accumulation. It is a rare complication of long-standing, poorly controlled type 1 diabetes mellitus. We report a case of a 19-year-old woman with a history of poorly controlled diabetes mellitus and frequent admissions for diabetic ketoacidosis, who presented with abdominal pain, nausea, vomiting, and hepatomegaly. She was found to have diabetic ketoacidosis with persistently elevated serum lactate that did not improve with insulin infusions. She eventually underwent a liver biopsy, which showed excessive intracytoplasmic glycogen accumulation consistent with glycogenic hepatopathy.
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Azariadis K, Gatselis NK, Koukoulis GK, Dalekos GN. Glycogenic hepatopathy as a cause of severe deranged liver enzymes in a young patient with type 1 diabetes mellitus. BMJ Case Rep 2019; 12:12/3/e228524. [PMID: 30898943 DOI: 10.1136/bcr-2018-228524] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Glycogenic hepatopathy (GH) is a rare complication of poorly controlled type 1 diabetes mellitus (T1DM). We present a 19-year-old woman with T1DM and autoimmune thyroiditis who admitted to our department because of abrupt onset intermittent abdominal pain in the right upper quadrant accompanied by laboratory evidence of acute anicteric hepatitis. Physical examination revealed significant hepatomegaly but the common imagining studies were negative. Following exclusion of common causes of acute hepatitis and because of the presence of smooth muscle antibodies in a young female patient with already established two autoimmune diseases, a liver biopsy was performed in order to exclude the potential presence of autoimmune hepatitis. However, liver histology showed typical findings of GH. Intense treatment targeting strict glycemic control resulted in normalisation of liver biochemistry. This case underlines that GH should be considered as a rare cause of acute hepatitis in T1DM patients with poor glycemic control.
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Affiliation(s)
- Kalliopi Azariadis
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa, Greece
| | - Nikolaos K Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa, Greece.,Institute of Internal Medicine and Hepatology, Larissa, Greece
| | - George K Koukoulis
- Department of Pathology, University of Thessaly, Medical School, Larissa, Thessaly, Greece
| | - Georgios N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, University Hospital of Larissa, Larissa, Greece.,Institute of Internal Medicine and Hepatology, Larissa, Greece
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Young Man with Hepatomegaly: A Case of Glycogenic Hepatopathy. Case Reports Hepatol 2018; 2018:6037530. [PMID: 29850300 PMCID: PMC5925151 DOI: 10.1155/2018/6037530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/03/2018] [Indexed: 02/06/2023] Open
Abstract
Glycogenic hepatopathy is a rare but potentially reversible condition characterized by hepatomegaly and elevated liver enzymes occurring in poorly controlled type 1 diabetes mellitus patients and often requires a liver biopsy to confirm the diagnosis. We present the case of a young man who was admitted with diabetic ketoacidosis in the setting of poorly controlled diabetes mellitus type 1 and was noted to have significantly elevated transaminases that continued to worsen despite appropriate treatment of the diabetic ketoacidosis. A liver biopsy confirmed the diagnosis of glycogenic hepatopathy and the patient improved with diabetes control. The aim of this report is to shed light on possible causes of significant elevation of liver enzymes in patients presenting with diabetic ketoacidosis. In addition, we would like to raise awareness about the diagnosis, management, and prognosis of glycogenic hepatopathy and how to differentiate it from other hepatic conditions that have a similar presentation.
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Sherigar JM, Castro JD, Yin YM, Guss D, Mohanty SR. Glycogenic hepatopathy: A narrative review. World J Hepatol 2018; 10:172-185. [PMID: 29527255 PMCID: PMC5838438 DOI: 10.4254/wjh.v10.i2.172] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 12/22/2017] [Accepted: 01/24/2018] [Indexed: 02/06/2023] Open
Abstract
Glycogenic hepatopathy (GH) is a rare complication of the poorly controlled diabetes mellitus characterized by the transient liver dysfunction with elevated liver enzymes and associated hepatomegaly caused by the reversible accumulation of excess glycogen in the hepatocytes. It is predominantly seen in patients with longstanding type 1 diabetes mellitus and rarely reported in association with type 2 diabetes mellitus. Although it was first observed in the pediatric population, since then, it has been reported in adolescents and adults with or without ketoacidosis. The association of GH with hyperglycemia in diabetes has not been well established. One of the essential elements in the pathophysiology of development of GH is the wide fluctuation in both glucose and insulin levels. GH and non-alcoholic fatty liver disease (NAFLD) are clinically indistinguishable, and latter is more prevalent in diabetic patients and can progress to advanced liver disease and cirrhosis. Gradient dual-echo MRI can distinguish GH from NAFLD; however, GH can reliably be diagnosed only by liver biopsy. Adequate glycemic control can result in complete remission of clinical, laboratory and histological abnormalities. There has been a recent report of varying degree of liver fibrosis identified in patients with GH. Future studies are required to understand the biochemical defects underlying GH, noninvasive, rapid diagnostic tests for GH, and to assess the consequence of the fibrosis identified as severe fibrosis may progress to cirrhosis. Awareness of this entity in the medical community including specialists is low. Here we briefly reviewed the English literature on pathogenesis involved, recent progress in the evaluation, differential diagnosis, and management.
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Affiliation(s)
- Jagannath M Sherigar
- Department of Gastroenterology and Hepatology, NYP-Brooklyn Methodist Hospital, Brooklyn, NY 11215, United States
| | - Joline De Castro
- Department of Gastroenterology and Hepatology, NYP-Brooklyn Methodist Hospital, Brooklyn, NY 11215, United States
| | - Yong Mei Yin
- NYP-Brooklyn Methodist Hospital, Brooklyn, NY 11215, United States
| | - Debra Guss
- Department of Gastroenterology and Hepatology, NYP-Brooklyn Methodist Hospital, Brooklyn, NY 11215, United States
| | - Smruti R Mohanty
- Department of Gastroenterology and Hepatology, NYP-Brooklyn Methodist Hospital, Brooklyn, NY 11215, United States
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