Methyltestosterone-induced cholestasis. The importance of disproportionately low serum alkaline phosphatase level

We describe a 64-year-old man who developed cholestatic jaundice after receiving 20 to 40 mg of methyltestosterone daily for 6 months for impotence but failed to mention it as part of his drug history. He underwent endoscopic retrograde and papillotomy before a positive history for methyltestosterone ingestion could be obtained. Since methyltestosterone is most often used for sexual impotence, the patient may be quite reluctant to mention this hormone as part of his medication. A normal or mildly elevated alkaline phosphatase level, disproportionate to the level of hyperbilirubinemia seen in this patient and in all previous reports, appears to be characteristic of this phenomenon. This pattern of liver function abnormality can be a clue to suspect methyltestosterone as the causative agent and spare the patient unneeded expensive noninvasive and potentially harmful invasive procedures.