Medical Liver Disease: Problem Diagnoses for Practicing Pathologists
Dr. Grace Kim
Dr. Linda D. Ferrell
Dr. Sanjay Kakar
Section 3 -
Linda D. Ferrell
University of California
San Francisco, CA
In chronic HBV infections, ground glass cells containing hepatitis B surface antigen (HBsAg) can be
seen on H&E stained sections. The cytoplasm of these cells have a homogeneous lightly-staining,
eosinophilic appearance and often resembles a cytoplasmic inclusion body displacing the nucleus to the
periphery of the cell. The presence of HBsAg can be confirmed by positive staining with an
immunoperoxidase or orcein stain; the former is the more sensitive technique and easier to interpret.
HBV can also be identified by immunohistochemical staining for hepatitis B core antigen (HBcAg). HbsAg
has a blue or green hue on trichrome stain (depending on the blue or green collagen stain used).
These stains can be variably positive, depending on sample size and stage of disease. In acute HBV
infections, surface antigen staining is usually negative as the infected cells are effectively cleared
from the liver . The positive staining is, instead, usually seen in chronic hepatitis where the viral
proliferation outstrips the immune clearance. In late-stage chronic hepatitis or in long-term healthy
carriers, HBsAg can be present, but not HBcAg. This is thought to be due to viral genomic incorporation
into hepatocytic nuclear DNA so that the HBsAg is coded for, but viral DNA is not . HBcAg positivity
can often be found in immunocompromised patients and cytoplasmic core antigen may suggest active
replication of HBV. Staining for HBcAg is much more common in the nucleus than in the cytoplasm.
Hepatitis C virus seems to induce a milder form of hepatitis than HBV and some typical histological
differences between the two entities have been noted other than the presence of ground glass cells in
HBV. Acute hepatitis C can occur, but in only very rare instances, and essentially cannot be
differentiated histologically from other forms of acute hepatitis. In chronic HCV, lymphocyte
infiltration is greater and reactive changes in the duct epithelium are often seen, but the duct damage
is not extensive or severe enough to cause ductopenia. Lymphocytic infiltrates in the sinusoids are
often prominent and lymphocytic aggregates in the portal zones are typical findings. Fatty change of
hepatocytes is greater than that seen in HBV . No currently commercially available
immunohistochemical method of identifying HCV in liver biopsies appears to be consistently reliable
(personal observation and communications from other pathologists). Thus, PCR technology still serves
as the gold standard for viral identification and to determine viral load.
Aggressive Variants of HBV and HCV
Both HBV and HCV can cause more aggressive and cholestatic forms of hepatitis in the setting of an
immunocompromised patient. For HBV, this distinct variant was originally described in HBV-infected
recipients of liver allografts
Since then, this aggressive form has also been described in other
patients who are immunocompromised but do not have a liver allograft . The clinical course is
characterized by the rapid progression to liver failure and death. The microscopic picture is
characterized by periportal fibrosis, cholestasis, hepatocyte ballooning, and a relatively scant
The hepatitis B viral core and surface antigens are overexpressed in
these cases 
and the transcription of HBV DNA has been shown to be enhanced . Immunohistochemical
staining for HB core and surface antigen show marked positivity, involving the vast majority of the
Likewise, some patients with HCV who are immunocompromised can develop an aggressive cholestatic form,
which frequently results in rapidly progressive liver failure . These patients also have the
cholestasis and ballooned hepatocytes, usually with scant inflammatory infiltrate, with or without the
fibrosis that is characteristic of the HBV variant. Hepatocyte dropout/necrosis may be prominent. In
our experience, these patients generally have high viral titers by PCR analysis. It has been speculated
that in these patients, the immunosuppression enhances the dominance of viral quasispecies of enhanced
pathogenic potential, leading to the severe recurrent disease. Both of these aggressive forms typically
lead to liver failure within a year or so of onset, so the outcome is dismal.
Non-viral Causes of Chronic Viral-like Hepatitis
|TYPE ||CLINICAL PRESENTATION ||HISTOLOGY|
|Autoimmune ||Active chronic hepatitis; can be rapidly progressive ||Similar to hepatotropic viruses, plasma cells may be prominent|
|Steatohepatitis, generally Nonalcoholic type ||Mild chronic hepatitis ||Mild chronic hepatitis-like changes, with ballooned hepatocytes, fat, centrizonal fibrosis, possible Mallory hyaline|
|Wilsons disease ||Acute, including fulminant; chronic hepatitis ||Similar to hepatotropic viruses; copper deposits|
|Alpha-1-antitrypsin deficiency ||Chronic hepatitis ||Similar to hepatotropic viruses; AAT globules|
|Drug reactions ||Mostly acute, rarely chronic hepatitis ||Similar to hepatotropic viruses, may see prominence of eosinophils, granulomas, or cholestasis|
Autoimmune hepatitis (AIH), (no longer called "lupoid hepatitis" or used with the term "chronic" has
been subclassified into three forms characterized by differences in clinical presentations or the serum
antibodies identified. Most patients respond favorably to immunosuppressive therapy (prednisone), with a
resultant decrease in the activity of the disease, so their distinction from viral hepatitis or chronic
hepatitis due to other causes is important.
ClassicalType 1 AIH presents as hepatitis that primarily affects females
in the age ranges of 2-15 and 35-70 years. These patients have positive antinuclear antibody (ANA)
titers and some association (in about 10-20%) with other autoimmune disorders.
Type 2 AIH seems to present more in children (girls more than boys, age less than 15 years) and is
frequently associated with other autoimmune disorders (about 20%) as well. The anti-liver-kidney
microsomal (LKM-1) antibody is present in these patients, who often present with the clinical picture of
an acute or fulminant hepatitis. In these cases, it is often difficult to determine whether a
preexisting chronic hepatitis was present before the acute phase, so the lesions may be truly more acute
in nature. The type 2 variant in adult patients has also been associated with coinfection with hepatitis
C virus. In this group, some patients have been reported to respond favorably to interferon therapy
while others have been reported to show flares of hepatitis during interferon therapy, and then,
subsequently, respond to steroid therapy. It is generally thought that infection with hepatitis C may,
in fact, trigger an autoimmune reaction to the LKM-1 target antigen in patients who have a genetic
predisposition as evidenced by a high incidence of certain HLA antigens.
The most recently described variant, Type 3AIH, also occurs mostly in
women but with a later onset (mean age 37). About 25% of these patients will display the anti-soluble
liver antigen (SLA) only. These patients are seronegative for ANA and liver-kidney-microsomal antibody,
but 75% will have anti-smooth muscle antibody (SMA) or liver membrane antibody (LMA). In contrast to
types 1 and 2, systemic autoimmune manifestations are not typical.
AIH is often characterized by prominent plasma cell infiltrates not typically seen in HCV or HBV
hepatitis, but may display the prominent lymphoid aggregates and duct damage seen with HCV hepatitis.
However, patients with AIH seem to have more diffuse and severe piecemeal necrosis (interface hepatitis),
an increased incidence of bridging and confluent necrosis, and more rapid progression to cirrhosis than
patients with HCV. In addition, infiltration of mononuclear inflammatory cells tends to be diffuse with
AIH and focal with chronic HCV. Multinucleate hepatocytic giant cells have also been reported to occur
in autoimmune hepatitis.
Giant Cell Hepatitis
Recently, the ultrastructural analysis of a severe hepatitis with giant cells associated with the
presence of paramyxovirus has been described in children and adults. This hepatitis has been termed
"syncytial giant cell hepatitis", but this viral etiology is currently questioned. In addition, giant
cell hepatidites have also been described as rare forms of viral, drug, autoimmune, or
post-transplantation hepatitis; many of these may have a more chronic type of course.
This disease is included in those entities that can cause chronic hepatitis, but the more complete
picture including acute hepatitis presentation was discussed in the section on Acute Hepatitis. See that
syllabus section for details on clinical considerations, pathologic findings, and use of special stains
for identification of copper. Additional clinical screening criteria, testing standards, and genetic
characteristics are additionally discussed below.
Hepatic Presentation Guidelines as proposed by Brewer, Fink, and Hedera
Viral-negative hepatitis. Always screen for WD
Viral-positive hepatitis. Screen for WD if there are aspects of the
disease (such as neurological or behavioral symptoms) that do not fit a viral etiology
Cirrhosis, under the age of 40. Always screen for WD
Cirrhosis, age 40-60. Screen for Wilsons unless a definite etiology can
Acute, unexplained liver failure. Always screen for WD
Recommended screening methods for patients with hepatic presentation
(Brewer et al, ref 28)
Serum ceruloplasmin (Cp). Easy to do, and low serum Cp will point to
diagnosis in 75%. However, Cp levels can be normal as noted above, and many heterozygotes have an
intermediately low value. Thus, low Cp needs further workup.
24-hour urine copper. This value will be >100µg in symptomatic WD. A
lower value in symptomatic, untreated patients excludes the diagnosis. If the liver disease is
long-standing and has an obstructive component, the urine copper can be elevated in the absence of
Slit-lamp examination for Kayser-Fleisher (KF) rings is close to 100%
diagnostic for patients with neurological or psychiatric symptoms, but not nearly as helpful for hepatic
presentations. In fact, patients with obstructive liver disease may also develop KF rings.
Quantitative copper assay on liver biopsy. This is the gold standard for
diagnosis over 200 µg/g dry wight of liver (normal 20-50 µg/g ). However, these levels are not specific
as patients with obstructive liver disease (such as primary biliary cirrhosis, primary sclerosing
cholangitis) can have copper levels similar to those seen in Wilson's disease. Heterozygotes may have
some increase in levels, but typically not over 125µg/g. The liver biopsy can be negative by staining
for copper and positive by quantitative analysis.
Gene for Wilsons disease
The gene responsible for WD has been identified and designated as ATP7B. This gene codes for a
copper-binding, membrane bound ATPase. The mutations in this gene identified are numerous, and no one
mutation accounts for more than 30% of the total group of mutations, so most patients are compound
heterozygotes. Thus, it is also not practical to develop a DNA test for diagnosis. Perhaps the large
number of mutations may account for some of the variability in clinical and pathological presentations.
Alpha-1-antitrypsin (AAT) deficiency is characterized by the accumulation of AAT in hepatocytes.
Numerous alleles for the AAT gene have been described, but the most common allele is PiM. Homozygotes MM
have normal levels of AAT. The most common alleles resulting in AAT deficiency are PiZ and PiS, with
liver pathology occurring predominantly in patients with at least one Z allele. Homozygotes for the Z
allele may arise in patients of all ages (from neonates to adults) for unknown reasons, while MZ
phenotypes present in adults. Neonates present with cholestatic jaundice, and may develop serious liver
disease with cirrhosis and death during childhood. Those with the most severe course also have a paucity
of bile ducts. Other poor prognostic factors include persistence of jaundice beyond one year of age and
fibrosis on liver biopsy. When the lesion presents in adulthood, the patients tend to present with
cryptogenic cirrhosis, with the AAT globules identified on liver biopsy.
The characteristic microscopic finding is the presence of PASD positive cytoplasmic globules found
mainly in the periportal zone or periphery of the cirrhotic nodule. The globules are usually present in
neonates as well as in adults. These globules will vary in size, and their exact composition as AAT
should be confirmed by immunohistochemical means. Typically stained larger globules show a distinct
outer dark ring with a pale center. Ultrastructural examination reveals dilated cisternae that contain
flocculent or granular to fibrillar material. Large numbers of AAT globules have also been noted in
alcohol associated disease and other entities, so phenotyping is necessary for definitive diagnosis.
Drug reactions must often be considered in the differential diagnosis of hepatitis of various types,
but drugs only rarely truly cause a chronic hepatitis. Such agents can include etretinate, lisinopril,
sulphonamides, and trazadone. Some of these chronic syndromes overlap features of autoimmune hepatitis,
including the presence of autoimmune antibodies (SMA, ANA, anti-DNA), as in the case of minocycline,
nitrofurantoin, and oxyphenisatin
A hepatitis-like mononuclear infiltrate that could be confused for hepatitis may be frequently seen in
primary biliary cirrhosis, especially in the early stages. The infiltrate consists of increased
sinusoidal lymphocytes and interface hepatitis, but the hepatocytes in the areas of infiltrate often do
not show much evidence of injury, in contrast to chronic hepatitis. However, spotty hepatocyte necrosis
(apoptosis) can be seen quite frequently, and rarely, centrilobular necrosis with venulitis can be
noted. In such cases, clinical correlation is important and examination for early changes of ductopenia
or granulomatous lesions is essential. Primary sclerosing cholangitis can also show some degree of
similar hepatitis-like infiltrates, although it does not tend to have the spotty necrosis.
Chronic Hepatitis - Grading and Staging
Table 1: Grading and Staging - Portal and Lobular Inflammatory Activity - Grade*
|0 ||None or minimal portal inflammation, no hepatocyte necrosis|
|1 ||Portal and/or lobular inflammation without significant evidence of hepatocyte necrosis|
|2 ||Mild interface hepatitis (piecemeal necrosis and disruption of limiting plate) and/or focal lobular hepatocyte necrosis|
|3 ||Moderate limiting plate (interface hepatitis) and/or severe focal cell necrosis (confluent necrosis)|
|4 ||Severe limiting plate and/or bridging necrosis|
Fibrosis - Stage
|0 ||No fibrosis|
|1 ||Mildly enlarged portal tracts (fibrous portal expansion)|
|2 ||Periportal or portal-portal septa (not prominent) with intact architecture, or periportal fibrosis|
|3 ||Septal fibrosis with architectural distortion or bridging fibrosis; no obvious cirrhosis|
|4 ||Probable or definite cirrhosis|
*Grade 1 inflammatory changes were formerly termed chronic persistent hepatitis; Grade 2-mild,
3-moderate, and 4-severe chronic active hepatitis.
Table 2-A complex grading and staging system (modified from Ishak et al
* Does not include diffuse sinusoidal infiltration by inflammatory cells
N.B. Other features such as bile duct damage should be noted but not scored
|A. Periportal or periseptal interface hepatitis (piecemeal necrosis)|
|Mild (focal, few portal areas) ||1|
|Mild/moderate (focal, most portal areas ||2|
|Moderate (continuous around <50% of tracts or septa) ||3|
|Severe (continuous around >50% of tracts or septa) ||4|
|B. Confluent necrosis|
|Focal confluent necrosis ||1|
|Zone 3 necrosis in some areas ||2|
|Zone 3 necrosis in most areas ||3|
|Zone 3 necrosis + occasional portal-central (P-C) bridging ||4|
|Zone 3 necrosis + multiple P-C bridging ||5|
|Panacinar or multiacinar necrosis ||6|
|C. Focal (spotty) lytic necrosis, apoptosis and focal inflammation*|
|One focus or less per 10x objective ||1|
|Two to four foci per 10x objective ||2|
|Five to ten foci per 10x objective ||3|
|More than ten foci per 10x objective ||4|
|D. Portal inflammation|
|Mild, some or all portal areas ||1|
|Moderate, some or all portal areas ||2|
|Moderate/marked, all portal areas ||3|
|Marked, all portal areas ||4|
|Architectural changes, fibrosis and cirrhosis|
| ||No fibrosis ||0|
|Fibrous expansion of some portal areas, with or without short fibrous septa ||1|
|Fibrous expansion of most portal areas, with or without short fibrous septa ||2|
|Fibrous expansion of most portal areas with occasional portal to portal (P-P) bridging ||3|
|Fibrous expansion of portal areas with marked bridging (portal to portal (P-P) as well as portal to central (P-C) ||4|
|Marked bridging (P-P and/or P-C) with occasional nodules (incomplete cirrhosis) ||5|
|Cirrhosis, probable or definite |
References for HBV, HCV, grade/stage
- Gerber M, Thung S. The diagnostic value of immunohistochemical demonstration of hepatitis viral antigens in the liver. Human Pathology 1987;18:771-774.
- Scheuer P, Ashrafzadeh P, Sherlock S, Brown D, Dusheiko G. The pathology of hepatitis C. Hepatology 1992;15:567-571.
- Sola I, Fernandez J, Idoate M, Diaz L, De Alava E. Nonspecificity of the paraffin-reactive hepatitis C virus monoclonal antibodies clones Tordji-22 and Tordji-32 due to cross-reaction with mitochondrial proteins. Modern Pathology 1997;10:147A.
- Vartanian R, Dupuis B, Rock N, Anderson F, Owen D. Nonspecificity of the novel paraffin-reactive hepatitis C virus monoclonal antibody, clone Tordji-22. Modern Pathology 1996;9:138A.
- Lefkowitch J, Goldstein H, Yatto R, Gerber M. Cytopathic liver injury in acute delta virus hepatitis. Gastroenterology 1987;92:1262-1266.
- Govindarajan S, DeCock K, Peters R. Morphologic and immunohistochemical features of fulminant delta hepatitis. Human Pathology 1985;16:262-267.
- Davies S, Portmann B, O'Grady J, et al. Hepatic histological findings after transplantation for chronic hepatitis B virus infection, including a unique pattern of fibrosing cholestatic hepatitis. Hepatology 1991;13:150-157.
- Benner K, Lee R, Keeffe E, Lopez R, Sasaki A, Wright Pinson C. Fibrosing cytolytic liver failure secondary to recurrent hepatitis B after liver transplantation. Gastroenterology 1992;103:1307-1312.
- Lam P, Wachs ME, Somberg KA, Vincenti F, Lake JR, Ferrell LD. Fibrosing cholestatic hepatitis in renal transplant recipients. Transplantation 1996;61(3):378-381.
- Mason A, Wick M, White H, et al. Increased hepatocyte expression of hepatitis B virus transcription in patients with features of fibrosing cholestatic hepatitis. Gastroenterology 1993;105:237.
- Taga S, Washington M, Terrault N, Wright T, Somberg K, Ferrell L. Cholestatic hepatitis C in liver allografts. Liver Transplantation and Surgery 1998;4:304-310.
- Ishak K, Baptista A, Bianchi L, et al. Histological grading and staging of chronic hepatitis. Journal of Hepatology 1995;22:696-699.
- Knodell R, Ishak K, Black W, et al. Formulation and application of a numerical scoring system for assessing histological activity in asymptomatic chronic active hepatitis. Hepatology 1981;1:431-435.
- Tsui W. New classification of chronic hepatitis and more. Advances in Anatomic Pathology 1996;3:64-70.
References for other forms of chronic hepatitis
- Johnson P, McFarlane I, Feddleston A. The natural course and heterogeneity of autoimmune-type chronic active hepatitis. Seminars in Liver Disease 1991;11:187-196.
- Gregoria G, Portmann B, Reid F, et al. Autoimmune hepatitis in childhood: a 20-year experience. Hepatology 1997;25:541-547.
- Garson J, Lenzi M, Ring C, et al. Hepatitis C Viremia in adults with type 2 autoimmune hepatitis.Journal of medicalVirology 1991; 34:223-226.
- Lenzi M, Ballardini G, Fusconi M, et al. Type 2 autoimmune hepatitis and hepatitis C virus infection. Lancet 1990; 335:258-259.
- Todros L, Touscoz G, D'Urso N, et al. Hepatitis C virus-related chronic liver disease with autoantibodies to liver-kidney microsomes (LKM). Clinical characterization from idiopathic LKM-positive disorders. Journal of Hepatology 1991;13:128-31.
- Garcia-Buey L, Garcia-Monzon C, Rodriguez S, et al. Latent autoimmune hepatitis triggered during interferon therapy in patients with chronic hepatitis C. Gastroenterology 1995;108:1770-1777.
- Bach N, Thung S, Schaffner F. The histological features of chronic hepatitis C and autoimmune chronic hepatitis: a comparative analysis. Hepatology 1992;15:572-577.
- Devaney K, Goodman Z, Ishak K. Postinfantile giant-cell transformation in hepatitis. Hepatology 1992;16:327-333.
- Pappo O, Yunis E, Jordan J, et al. Recurrent and de novo giant cell hepatitis after orthotopic liver transplantation. American Journal of Surgical Pathology 1994;18:804-813.
- Phillips M, Blendis L, Poucell S, et al. Syncytial giant cell hepatitis: sporadic hepatitis with distinctive pathological features, a severe clinical course, and paramyxoviral features. New England Journal of Medicine 1991;324:455-460.
- Cairns A, McMahon R. Giant cell hepatitis associated with systemic lupus erythematosus. J Clin Pathol 1996;49(2):183-184.
- Scott J, Gollan J, Samourian S, Sherlock S. Wilson's disease, presenting as chronic active hepatitis. Gastroenterology 1978;74:645-651.
- Davies S, Williams R, Portmann B. Hepatic morphology and histochemistry of Wilson's disease presenting as fulminant hepatic failure: a study of 11 cases. Histopathology 1989;15:385-394.
- Brewer GJ, Fink JK, and Hedera P. Diagnosis and treatment of Wilson's disease. Sem Neurol 1999;19:261-270.
- Stromeyer F, Ishak K. Histology of the liver in Wilson's Disease: a study of 34 cases. American Journal of Clinical Pathology 1980;73:12-24.
- Ferenci P. Wilson's Disease. Clin Gastroenterol Hepatol 2005;3(8):726-33.
- Kitzberger R, Madl C, and Ferenci P. Wilson Disease. Meta Brain Dis 2005;20(4):295-302.
- Ala A, Borjigin J, Rochwarger A, and Schilsky M. Wilson Disease in Septuagenarian siblings: Raising the bar for diagnosis. Hepatol 2005;41:668-670.
- Hodges J, Millward-Sadler G, Barbatis C, Wright R. Heterozygous MZ alpha-1-antitrypsin deficiency in adults with chronic active hepatitis and cryptogenic cirrhosis. New England Journal of Medicine 1981;304:557-560.
- Ghishan F, Greene H. Liver disease in children with PiZZ alpha-1-antitrypsin deficiency. Hepatology 1988;8:307-310.
- Pariente E, Degott C, Martin J, Feldmann G, Potet F, Benhamou J. Hepatocytic PAS-positive diastase-resistant inclusions in the absence of alpha-1-antitrypsin deficiency: high prevalence in alcoholic cirrhosis. American Journal of Clinical Pathology 1981;76:299-302.
- Yunis E, Agostini R, Glew R. Fine structural observations of the liver in alpha-1-antitrypsin deficiency. American Journal of Pathology 1976;82:265-281.
- Hall P, Herrmann R, Brennan J, Mackinnon M. Detection of alpha-1-antitrypsin in hepatocytes in acute and chronic hepatitis. Pathology 1987;19:415-418.
- Ranes J, Stoller JK. A review of alpha-1 antitrysin deficiency. Sem Respir Crit Care Med 2005;26(2):154-66.
- Nakanuma Y. Necroinflammatory changes in hepatic lobules in primary biliary cirrhosis with less well-defined cholestatic changes. Human Pathology 1993;24:378-383.