S2772 Drug-Induced Liver Injury Caused by a Synthetic, Androgenic-Anabolic Steroid Hormone “Supplement”

Introduction: Androgenic & anabolic steroids (AAS) cause 4 distinct forms of liver injury: transient serum enzyme elevations, bland cholestasis, peliosis hepatis, and hepatic tumors. The mechanism of injury likely results from androgen receptor-mediated genomic activation that elevates hepatotoxic ROS and alters expression of canalicular bile acid, promoting a cholestatic environment. We report a case of a healthy young adult who developed significant cholestatic jaundice after the use of the prohormone supplement 4Midable Mass Case Description/Methods: A 39 y/o healthy male presented with a 1-week history of vague abdominal pain, jaundice, and dark urine. He denied heavy alcohol use, illicit drugs, or family history of hepatitis. Labs were notable for AST 129 IU/L, ALT 380 IU/L, ALP 101 IU/L, T. Bili 12.9 mg/dl. Further workup and labs are shown in Table 1. Dedicated contrast CT and MRCP were non-revealing. Upon further history, he admitted to using 4Midable Mass 2 weeks prior to presentation. Over the next few days, his LFTs downtrend and he was discharged. A presumptive diagnosis of DILI was made. However, the patient re-presented 27-days later with worsening jaundice, fatigue, and pruritus. T.Bili was now 37.5 mg/dL,D.Bili 26.3 mg/dL and a subsequent MRCP showed a focal narrowing of the common hepatic duct. Based on these new labs and imaging findings, an ERCP was performed showing a normal size CBD with no stricture, nevertheless, an empiric stent was placed. Due to the synthetic dysfunction and rising INR 2.4, a core liver biopsy was obtained, revealing centrilobular cholestasis and hepatitis. A diagnosis of mix hepatocellular and cholestasis from DILI was made. Empiric prednisone and ursodiol were started with normalization of LFTs over 3 months and avoiding possible liver transplantation. Discussion: Prohormones sold as supplements have gained popularity in recent times as an alternative to build body mass. The androgen derivatives comprising 4Midable Mass (dymethazine,methylsten-bolone,methyl 1-a,methoxygonadiene),have been implicated in cases of DILI. In this case, a 25-day use of these steroids preceded intrahepatic cholestasis and hepatitis and necessitated empiric stent placement & prednisone to alleviate severe hyperbilirubinemia. Thus, in young, previously healthy individuals presenting with a clinical constellation suggestive of hepatocellular or cholestatic liver injury, inquiry should be made of anabolic steroid use, and efforts made to warn patients against the innocuous façade of these drugs.Figure 1.: (a) High power magnification showing central vein with canalicular cholestasis with inflammation; (b) PAS-diastase showing necrotic hepatocytes.Table 1.: Hospital Course Liver Function Test Trend: Day 1-4 initial admission, Day 27-37 readmission labs. Further workup, including acute and chronic hepatitis panel, ANA, ASMA, AMA, acetaminophen level, HSV, CMV, EBV, and COVID-19 tests were all negative.