Glycogenic Hepatopathy

An underrecognized cause of hepatomegaly in uncontrolled type I diabetes

A 29-year-old woman with a past medical history of poorly controlled type 1 diabetes and autoimmune hypothyroidism presented to the emergency department for evaluation of abdominal pain, nausea and vomiting. The patient was a cocaine user, but she did not use alcohol and did not smoke. Her current medications included Insulin aspart, Insulin degludec, L-thyroxine and Pantoprazole. She reported no use of over-thecounter medication or herbal and dietary supplements. acute distress. The abdomen was nondistended and soft with diffusely tenderness and a smooth palpable liver 3 to 4 cm below the costal margin. Laboratory studies was significant for glucose 539 mg/dL (normal 65-110), alkaline phosphatase 153 U/L (normal 35-105), gamma-GT 44 U/L (normal <36), lactate 42,1 mg/dL (normal 4,5-19,8), arterial pH 7,32 (normal 7,35-7,45) and HbA1c 11% (4,5-6). A computed tomography (figure 1; panel A and B) and liver biopsy (figure 1; panel C and D) were performed.

Hepatopathy Associated With Type 1 Diabetes: Distinguishing Non-alcoholic Fatty Liver Disease From Glycogenic Hepatopathy

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.

Glycogenic hepatopathy in children with poorly controlled type 1 diabetes mellitus

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.