Jaundice From Diabetes Therapy

In January 2013, a 41-year-old man presented for follow-up to our diabetes unit with jaundice, fatigue, dark urine, and stool discoloration. Four weeks earlier, he had suffered a sudden sensorineural hearing loss and was treated with a prednisolone taper scheme starting with 250 mg q.i.d. in addition to α-lipoic acid. Fasting hyperglycemia (274 mg/dL) was detected after initiation of the therapy. Further laboratory workup revealed a preexisting type 2 diabetes (HbA1c 11.8% [105 mmol/mol], no GAD2 antibodies). Transaminases were normal. Insulin glargine and metformin 500 mg t.i.d. were initiated. Upon follow-up, the patient reported that fatigue and yellow sclera manifested 4 days before. Thereafter, he stopped taking his medication. Physical examination was unremarkable except for jaundice. Total bilirubin was 18.1 mg/dL, aspartate aminotransferase 419 units/L, alanine aminotransferase 863 units/L, alkaline phosphatase 479 units/L, and γ-glutamyl transferase 2,181 units/L. Differential blood count was normal apart from mild eosinophilia (5.7%). The patient had no history of gastrointestinal …