What are the potential causes of low alkaline phosphatase (alkphos), globulin, and albumin/globulin ratio in a 50-year-old female with a history of hysterectomy, adrenocorticotropic hormone (ACTH) level of 6, and cortisol level of 16, who has been treated for multiple sclerosis (MS)?

From the Guidelines

Low alkaline phosphatase (ALP), globulin, and albumin/globulin ratio in a 50-year-old female with a history of hysterectomy, adrenocorticotropic hormone (ACTH) level of 6, and cortisol level of 16, who has been treated for multiple sclerosis (MS), could indicate malnutrition, protein deficiency, liver dysfunction, or adrenal insufficiency. The patient's laboratory findings may suggest several conditions, including malnutrition, protein deficiency, liver dysfunction, or adrenal insufficiency. For this patient with MS history, comprehensive liver function testing should include AST, ALT, total bilirubin, direct bilirubin, GGT, total protein, albumin, and prothrombin time, as recommended by the guidelines on the management of abnormal liver blood tests 1.

Potential Causes and Evaluation

• Malnutrition or protein deficiency: Evaluate the patient's nutritional status and consider consulting a dietitian.
• Liver dysfunction: Perform a liver aetiology screen, including abdominal ultrasound scan, hepatitis B surface antigen, hepatitis C antibody, anti-mitochondrial antibody, anti-smooth muscle antibody, antinuclear antibody, serum immunoglobulins, simultaneous serum ferritin and transferrin saturation, as recommended by the guidelines 1.
• Adrenal insufficiency: Further endocrine workup, including thyroid function tests and a morning cortisol level, would help clarify the underlying cause of these laboratory abnormalities.
• MS treatments: Consider the potential effects of MS treatments, such as corticosteroids or immunosuppressants, on the patient's laboratory values.

Clinical Approach

The patient's ACTH and cortisol levels suggest possible adrenal dysfunction, which could be related to prior steroid treatment for MS 1. The hysterectomy history is likely unrelated to these laboratory abnormalities unless there were complications affecting liver function or nutrition.

Recommendations

• Comprehensive liver function testing and liver aetiology screen should be performed to evaluate the patient's liver function and identify potential causes of the laboratory abnormalities.
• Further endocrine workup, including thyroid function tests and a morning cortisol level, should be considered to evaluate the patient's adrenal function.
• The patient's nutritional status should be evaluated, and a dietitian should be consulted if necessary.
• The potential effects of MS treatments on the patient's laboratory values should be considered, and alternative treatments should be explored if necessary.

From the Research

Potential Causes of Abnormal Liver Function Tests

The patient's history of multiple sclerosis (MS) and treatment for the condition may be related to the abnormal liver function tests, including low alkaline phosphatase (alkphos), globulin, and albumin/globulin ratio.

• The study by 2 found that patients with MS had a higher risk of abnormal liver test results, including alanine aminotransferase (ALT) and aspartate aminotransferase (AST), but not alkaline phosphatase or total bilirubin.
• However, the patient's treatment for MS may be a contributing factor to the abnormal liver function tests, as some disease-modifying therapies (DMTs) used to treat MS can have adverse effects on the liver 3, 4.

Relationship Between MS Treatment and Liver Function

The treatment of MS can be complex, and the choice of medication depends on various factors, including the patient's disease course and medical history.

• The study by 4 discussed the European and American guidelines for MS treatment, which provide recommendations for the management of MS, including the use of DMTs and the monitoring of liver function.
• However, there is limited information available on the specific effects of MS treatment on liver function tests, including alkaline phosphatase, globulin, and albumin/globulin ratio.

Other Potential Causes of Abnormal Liver Function Tests

Other factors, such as liver disease or infection, may also contribute to the abnormal liver function tests.

• The study by 5 investigated the ratio of aspartate aminotransferase to alanine aminotransferase and alkaline phosphatase to total bilirubin in diagnosing Wilsonian acute liver failure in children, but the results may not be directly applicable to this patient's case.
• The study by 6 found that Opisthorchis viverrini infection can cause changes in liver function tests, including a decrease in total protein and albumin, but the patient's medical history does not indicate a parasitic infection.