Excess Cortisol of Cushing’s Likely Triggered Woman’s Hepatitis C Flare

Margarida Maia, PhD avatar

by Margarida Maia, PhD |

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Excessive cortisol might have triggered an acute exacerbation of chronic hepatitis C — an inflammation of the liver caused by an infection with the hepatitis C virus — in a woman who also had Cushing’s syndrome, according to a recent report.

The woman, who was scheduled to undergo an adrenalectomy — a surgery to remove one of the adrenal glands — was started on a medication to prevent the virus from multiplying and to help restore liver function. She recovered quickly and the surgery was performed safely as planned.

“This is the first report of Cushing’s syndrome causing acute exacerbation of chronic hepatitis C,” its scientists wrote. “Acute exacerbation of hepatitis C should be listed as a differential disease for liver disorders in patients with Cushing’s.” 

The report, “A case of acute exacerbation of chronic hepatitis C during the course of adrenal Cushing’s syndrome,” was published in the journal Clinical Case Reports by a team of researchers in Japan.

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The hepatitis C virus is carried and passed on to others through the blood and other bodily fluids. People infected with the virus may not have any symptoms until the liver is damaged badly enough and stops working. Those who appear to have recovered from the infection may still have small amounts of the virus that remain dormant (latent) in the body.

A reactivation of the latent virus may occur following treatment with an immunosuppressant or anti-cancer medication. There have also been reports of reactivation of the hepatitis B virus — another virus that infects the liver — caused by Cushing’s syndrome.

Cushing’s syndrome occurs when the adrenal glands sitting stop the kidneys make too much cortisol, a type of steroid hormone. However, “no acute exacerbation of chronic hepatitis C [caused by an excess of cortisol] has been reported so far,” the researchers wrote.

They reported the case of a 50-year-old woman who experienced an acute exacerbation of chronic hepatitis C over the course of Cushing’s syndrome.

She first visited the hospital in Sapporo, Japan, for high blood pressure that did not respond to treatment. A CT scan revealed a non-cancerous lump in the left adrenal gland that measured about three centimeters in its widest point.

A physical exam revealed that she had excessive fat around the waist (central obesity) and behind the neck (“buffalo hump”), swelling in the face (“moon face”), and red streaks across the skin (stretch marks), all of which are typical symptoms of Cushing’s syndrome.

A blood test revealed higher-than-normal levels of cortisol at night, when they are normally low. Cortisol levels remained higher-than-normal after a cortisol suppression test. In this test, the corticosteroid dexamethasone is used to see if a drop in the levels of adrenocorticotropic hormone (ACTH), a hormone that drives the adrenal glands to make cortisol, has an effect on cortisol levels in the body. 

Further blood testing revealed the presence of antibodies against the hepatitis C virus and an increase in ALT, a liver enzyme that, when present at high levels, can indicate the presence of liver damage and inflammation. The virus RNA level was 4.1 logarithmic international units per milliliter (log IU/mL).

“Based on the above test results, she was diagnosed with chronic hepatitis C and adrenal Cushing’s syndrome,” the researchers wrote, and an adrenalectomy was scheduled.

However, two months later, liver enzyme levels increased. Her virus RNA level also rose to 6.4 log IU/mL, indicating an acute exacerbation of chronic hepatitis C. A closer examination of the liver revealed an infiltration of certain types of inflammatory cells, as well as tissue scarring (fibrosis).

“The treatment policy was changed, in order to treat hepatitis C before the left adrenal resection, and administration of glecaprevir/pibrentasvir was started,” the researchers wrote.

Glecaprevir/pibrentasvir, sold under the brand name Mavyret or Maviret, works by blocking two proteins that are essential for the hepatitis C virus to multiply. Two weeks after starting treatment, her liver enzyme levels returned to normal and the virus quickly cleared from her body.

Adrenalectomy was performed safely nine months after the initial diagnosis. Her blood pressure dropped, and hepatitis C and Cushing’s syndrome were both considered to have been cured.

“As far as we can determine, no cases of Cushing’s syndrome causing [hepatitis C virus] reactivation or acute exacerbation of chronic hepatitis C have been reported and similar cases may be latent,” the researchers wrote.

“If Cushing’s syndrome is complicated by an acute exacerbation of hepatitis C, clinicians should consider including treatment strategies such as in this case,” they added.