HELEN WANG
Beth Israel Deaconess Medical Center
Boston, MA
A 43-year-old woman who is status post cadaveric renal transplant eleven years before, now presents
with acute liver failure. Five years after the renal transplant she was noted to have hepatitis B,
but had normal liver function tests up till at least a few months before the presentation. She was in
her usual state of health until two weeks prior to presentation when she developed right upper
quadrant pain followed by nausea and vomiting and then jaundice. She presented to the emergency
department of an outside hospital where an ultrasound revealed gallbladder edema. At that time her
liver function tests and INR were noted to be elevated, and the patient was discharged home. She
subsequently developed increase in abdominal girth and an increase in abdominal pain, nausea and
vomiting, as well as generalized weakness. She presented to the same outside hospital again ten days
later and was admitted with a diagnosis of "hepatitis". An abdominal CT revealed ascites, edema of
the colon and small bowel wall. She was treated conservatively and given Unasyn for presumed
cholecystitis/cholangitis. She was then transferred to the Beth Israel Deaconess Medical Center for
further workup.
On presentation she complained of diarrhea or loose stool for two weeks in
addition to the above symptoms. She had some shortness of breath secondary to abdominal distention.
She denied any fevers, chills, bright red blood per rectum or melena. She had no recent travel or
sick contact. Neither did she have unusual or undercooked food. She claimed her liver and kidney to
be working normally until this acute process. She had no history of hypercoagulability in herself or
her family.
In addition to the history of kidney transplant for end stage renal disease of
unclear etiology and subsequent hepatitis B, her medical history was significant for hypertension and
percholesterolemia. Her medications at home included Imuran, Sandimmune, predinisone, Lasix,
Procardia, Tenormin and occasional Tylenol. She did not smoke or use alcohol or any other drugs.
Physical examination showed an overweight middle-aged woman in no acute distress with a heart rate of
105 and respiratory rate of 22. The exam was remarkable for a softly distended abdomen with
tenderness in the right upper quadrant, but without guarding or rebound. Mild edema was noted on the
lower extremities. Laboratory tests were remarkable for an elevated white count to 18.1 with a
differential of 89 polys, 9 bands, and 1 lymphocyte. Coags were notable for an elevated INR. Liver
function tests were: AST 408, ALT 288, alkaline phosphatase 221, amylase 77, total bilirubin 27.9,
direct bilirubin 17, indirect bilirubin 10.9, and albumin 2.5.
She was admitted to the hospital
with acute liver failure. A full hepatitis panel including hepatitis A, B, C, D, and E, CMV antibody
and antigen, EBV antibody panel revealed only hepatitis B surface antigen and e-antigen positivity.
Right upper quadrant ultrasound revealed no bile duct dilation and no evidence of portal vein or
hepatic vein thrombosis. A transjugular liver biopsy was performed.
HOWARD SHULMAN
Fred Hutchinson Cancer Center
Seattle, WA
A 40 year-old with ALL received an allogeneic matched sibling hematopoietic stem cell transplant (HCT)
in 2002.The only posttransplant (PT) problem, mild skin graft-versus-host disease (GVHD), resolved
with prednisone. At six months, tapering of prophylactic prednisone and cyclosporin were completed.
At 8.5 months PT she finished a 2 week course of famciclovir for zoster. Two weeks later, the LFTs
revealed a normal bilirubin with elevations of alkaline phosphatase (AP)406, SGOT 112, and SGPT 133.
Within 2 weeks, SGOT had risen to 2,086, SGPT 1,641, AP 347. The first liver biopsy was performed 26
days after the onset of LFT elevations, 10 months PT. Foscarnet was given for three weeks for
treatment of preemptive zoster hepatitis. In the ensuing month the SGOT/SGPT and AP levels markedly
declined. However, the SGOT rose again to 475 and the bilirubin continued to rise, peaking at 30
mg/dl 33 days later when a second liver biopsy was done, 11 months PT. The patient had a history of
hepatitis A reactivity pretransplant, but was currently IgM negative. The patient was CMV antibody
positive but multiple PCR studies for circulating CMV were negative. Tests for hepatitis viruses B
and C were negative. All cultures were negative. There was no indication of any potentially
hepatotoxic drugs.
MICHAEL TORBENSON
Johns Hopkins Hospital
Baltimore, MD
A three month old female presented with weight loss, poor feeding, and oligouria. Imaging studies
revealed heart failure and massive hepatomegaly. The liver contained multiple vascular lesions
measuring up to 6 cm in greatest dimension. Malrotation of the gut was also noted, with the appendix
located in the left upper quadrant. Medical therapy including steroids and embolization failed and a
liver transplant was performed.
STEFAN G. HÜBSCHER
University of Birmingham
Birmingham, United Kingdom
This 28 year old woman presented with upper abdominal pain. There was a history of oral contraceptive
pill use. Imaging studies (CT scan) demonstrated a well circumscribed lesion in the left lobe of
liver 13cm in maximum dimension, with an area of suspected intra-tumoral haemorrhage. The clinical
and radiological diagnosis was liver cell adenoma. A liver resection was carried out 6 weeks after
the initial clinical presentation.
LARRY BURGART
Mayo Clinic
Rochester, MN
A 39 year old man presented with fatigue, pruritis and weight loss. Physical exam revealed low grade
ascites, mildly enlarged liver and splenomegaly. Alkaline phosphatase was 2.5x normal and
transaminases were barely out of the normal range.
