Addison's disease and hypertransaminasemia

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.

Apoptosis in subicular neurons: A comparison between suicide and Addison's disease

BACKGROUND

Stress and depression shows possible links to neuronal death in hippocampus. Subiculum plays a prominent role in limbic stress integration and direct effect of corticosteroids on subicular neurons needs to be defined to assess its subsequent impact on hippocampal plasticity.

AIM

This study was intended to assess apoptosis in subicular neurons of a young depressed suicide victim, where presumably stress induced excess of corticosteroids and a case of young Addison's disease with low level of corticosteroids.

MATERIALS AND METHOD

Both bilateral adrenal glands (Addison's) and subiculum (both cases) were initially stained with hematoxylin and eosin; subicular neurons of both cases were examined for the degree of apoptosis using 'ApopTag Kit'. Apoptotic cell counts were expressed as average number of labeled cells/mm 2 and the results were analysed statistically using a non-parametric Mann-Whitney U test.

RESULT

Apoptotic neurons were detected in the subicular region of both suicide and Addison victims, and it is statistically significant in both right and left between the cases (P < 0.05). In suicide victim, the neuronal apoptosis is considerably significant between the two hemispheres (P < 0.05), in contrast to Addison disease where the number of neuronal cell death between right and left was statistically insignificant (P > 0.05).

CONCLUSION

The present study confirms the vulnerability of the subicular neurons to apoptosis, possibly due to corticosteroids in both ends of spectrum.