Severe Starvation-Induced Hepatocyte Autophagy as a Cause of Acute Liver Injury in Anorexia Nervosa: A Case Report

Introduction. Mild elevation of transaminase may be observed in anorexia nervosa, but acute liver injury is uncommon. A complex programmed cell death in response to starvation, called autophagy, has been described in experimental and human studies. Case Presentation. A 24-year-old woman suffering from anorexia nervosa was hospitalized for severe malnutrition. At admission, there were biological signs of acute liver injury but no electrolytic imbalance. After having ruled out the most common causes of liver injury, the patient was carefully refed. As liver tests remained abnormal, liver biopsy was performed. At histology and electron microscopy, numerous signs suggestive of starvation-induced hepatocyte autophagy were found. Discussion. Severe starvation can be associated with acute liver injury that is slowly reversible with careful enteral nutrition. In this clinical situation, profound hepatic glycogen depletion in association with autophagy appears as the leading cause of liver injury. 1. Introduction Anorexia nervosa is a common eating disorder, particularly in women, with a lifetime prevalence estimated to be 0.3–0.9% [1]. This disorder is associated with numerous medical complications (cardiovascular problems, endocrine disorders, electrolyte and hematopoietic abnormalities, amenorrhea, and osteoporosis), among which changes in liver tests are frequent. A mild increase in serum aminotransferase levels is indeed observed in up to 60% of these patients [2, 3] leading the American Psychiatric Association to recommend a systematic assessment of liver tests for these patients [4]. Conversely, severe liver damage with a significant decrease in coagulation factors appears to be uncommon in patients with anorexia nervosa, although some cases have been reported [5]. Even if the mechanisms of liver injury during anorexia nervosa remain unclear, a complex programmed cell death in response to starvation, called autophagy, has been suggested in few studies to play a pivotal role in yeast and animals [6] as well as in human beings [7]. We report here the case of a 24-year-old woman with anorexia nervosa, who experienced acute liver injury in association with histological and electron microscopical evidence of liver autophagy that was slowly reversible following careful renutrition. 2. Case Presentation A 24-year-old woman was admitted for severe malnutrition and dehydration in the context of anorexia nervosa that was diagnosed one year ago. During this time, she had been hospitalized during 4 months with a transitory gain of six kilograms. She was treated with