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Gonzalez HC, Gordon SC. Hepatic Manifestations of Systemic Diseases. Med Clin North Am 2023; 107:465-489. [PMID: 37001948 DOI: 10.1016/j.mcna.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
In addition to being the primary target of infections such as viral hepatitis, the liver may also be affected by systemic disease. These include bacterial, mycotic, and viral infections, as well as autoimmune and infiltrative diseases. These conditions generally manifest as abnormal liver biochemistries, often with a cholestatic profile, and may present with additional signs/symptoms such as jaundice and fever. A high index of suspicion and familiarity with potential causal entities is necessary to guide appropriate testing, diagnosis, and treatment.
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Affiliation(s)
- Humberto C Gonzalez
- Division of Gastroenterology and Hepatology, Henry Ford Health, 2799 West Grand Boulevard, Detroit, MI 48202, USA; Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, USA.
| | - Stuart C Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health, 2799 West Grand Boulevard, Detroit, MI 48202, USA; Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, USA
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2
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Ikeda S, Sugihara T, Kihara T, Hoshino Y, Matsuki Y, Nagahara T, Oyama K, Okano JI, Kuwamoto S, Horie Y, Isomoto H. Chronic Active Epstein–Barr Virus Infection Indistinguishable from Autoimmune Hepatitis: A Case Report. Yonago Acta Med 2022; 65:160-165. [DOI: 10.33160/yam.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/01/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Suguru Ikeda
- Division of Medicine and Clinical Science, Department of Gastroenterology and Nephrology, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Takaaki Sugihara
- Division of Medicine and Clinical Science, Department of Gastroenterology and Nephrology, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Takuya Kihara
- Division of Medicine and Clinical Science, Department of Gastroenterology and Nephrology, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Yoshiki Hoshino
- Division of Medicine and Clinical Science, Department of Gastroenterology and Nephrology, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Yukako Matsuki
- Division of Medicine and Clinical Science, Department of Gastroenterology and Nephrology, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Takakazu Nagahara
- Division of Medicine and Clinical Science, Department of Gastroenterology and Nephrology, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Kenji Oyama
- Division of Medicine and Clinical Science, Department of Gastroenterology and Nephrology, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Jun-ichi Okano
- Division of Medicine and Clinical Science, Department of Gastroenterology and Nephrology, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Satoshi Kuwamoto
- Department of Pathology, Tottori University Hospital, Yonago 683-8504, Japan
| | - Yasushi Horie
- Department of Pathology, Tottori University Hospital, Yonago 683-8504, Japan
| | - Hajime Isomoto
- Division of Medicine and Clinical Science, Department of Gastroenterology and Nephrology, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
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3
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Jaffey JA. Canine intrahepatic biliary disease - what have we learned? J Small Anim Pract 2021; 63:167-173. [PMID: 34585753 DOI: 10.1111/jsap.13433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/08/2021] [Accepted: 09/06/2021] [Indexed: 12/07/2022]
Abstract
The intrahepatic biliary tract is essential for physiologic homeostasis. Disease that results in aberrant function can have serious deleterious consequences and result in considerable morbidity and mortality. This review aimed to summarise clinically relevant updates on intrahepatic biliary disorders in dogs including human corollaries.
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Affiliation(s)
- J A Jaffey
- Department of Specialty Medicine, Midwestern University, College of Veterinary Medicine, 19555 N 59th Avenue, Glendale, AZ, 85308, USA
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4
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Bunchorntavakul C, Reddy KR. Epstein-Barr Virus and Cytomegalovirus Infections of the Liver. Gastroenterol Clin North Am 2020; 49:331-346. [PMID: 32389366 DOI: 10.1016/j.gtc.2020.01.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Epstein-Barr virus (EBV) and cytomegalovirus (CMV) infections are common and are associated with a variety of liver manifestations. EBV and CMV infections, in immunocompetent hosts, commonly manifest as acute hepatitis, with severity varying from asymptomatic, self-limited icteric hepatitis to acute liver failure. Atypical manifestations, such as cholestasis, chronic hepatitis, precipitation of acute-on-chronic liver failure, and autoimmune hepatitis, are reported with EBV infection, whereas cholestasis, portal vein thrombosis, and Budd-Chiari syndrome are reported with CMV infection. In the setting of liver transplantation, CMV is the most common infectious complication and carries significant morbidity; EBV is the major cause of post-transplant lymphoproliferative disorders.
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Affiliation(s)
- Chalermrat Bunchorntavakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, 2 Phayathai Road, Ratchathewi, Bangkok 10400, Thailand
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Piawah S, Hyland C, Umetsu SE, Esserman LJ, Rugo HS, Chien AJ. A case report of vanishing bile duct syndrome after exposure to pexidartinib (PLX3397) and paclitaxel. NPJ Breast Cancer 2019; 5:17. [PMID: 31240240 PMCID: PMC6570645 DOI: 10.1038/s41523-019-0112-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 05/16/2019] [Indexed: 12/12/2022] Open
Abstract
Pexidartinib (PLX3397) is a small molecule tyrosine kinase and colony-stimulating factor-1 inhibitor with FDA breakthrough therapy designation for tenosynovial giant-cell tumor, and currently under study in several other tumor types, including breast cancer, non-Hodgkin's lymphoma, and glioblastoma. Here, we report a case of severe drug-induced liver injury requiring liver transplantation due to vanishing bile duct syndrome (VBDS) after exposure to pexidartinib in the I-SPY 2 Trial, a phase 2 multicenter randomized neoadjuvant chemotherapy trial in patients with Stage II-III breast cancer. We also review the current literature on this rare, idiosyncratic, and potentially life-threatening entity.
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Affiliation(s)
- Sorbarikor Piawah
- Department of Medicine, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA USA
| | - Colby Hyland
- Department of Surgery, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA USA
| | - Sarah E. Umetsu
- Department of Pathology, University of California San Francisco, San Francisco, CA USA
| | - Laura J. Esserman
- Department of Surgery, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA USA
| | - Hope S. Rugo
- Department of Medicine, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA USA
| | - A. Jo Chien
- Department of Medicine, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA USA
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6
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Averbukh LD, Wu GY. Evidence for Viral Induction of Biliary Atresia: A Review. J Clin Transl Hepatol 2018; 6:410-419. [PMID: 30637219 PMCID: PMC6328731 DOI: 10.14218/jcth.2018.00046] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 09/05/2018] [Accepted: 09/07/2018] [Indexed: 12/14/2022] Open
Abstract
Biliary atresia (BA) is a childhood disease which manifests with abnormal narrowing, blockage or complete absence of bile ducts within the liver. Many possible etiologies have been reported for the development of BA, including congenital, perinatal and acquired conditions. Since the 1970's, there has been increasing evidence linking BA development to viral perinatal infections. The viral vectors most commonly implicated include members of the herpesviridae family (cytomegalovirus and Epstein-Barr virus) as well as those of the reoviridae family (reovirus and rotavirus). While extensive work has been done on a murine model of disease, the current review focuses primarily on evidence from human studies of viral vectors in children afflicted with BA.
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Affiliation(s)
- Leon D. Averbukh
- Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT, USA
- *Correspondence to: Leon D. Averbukh, Department of Medicine, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, 236 Farmington Ave., Farmington, CT 06030, USA. Tel: +1-347-306-4752, E-mail:
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7
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Liver Disease Associated With Systemic Viral Infection. ZAKIM AND BOYER'S HEPATOLOGY 2018. [PMCID: PMC7099665 DOI: 10.1016/b978-0-323-37591-7.00038-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Zhao Z, Bao L, Yu X, Zhu C, Xu J, Wang Y, Yin M, Li Y, Li W. Acute vanishing bile duct syndrome after therapy with cephalosporin, metronidazole, and clotrimazole: A case report. Medicine (Baltimore) 2017; 96:e8009. [PMID: 28885366 PMCID: PMC6392967 DOI: 10.1097/md.0000000000008009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
RATIONALE Vanishing bile duct syndrome (VBDS) consists of a series of diseases characterized by the loss of >50% bile duct in portal areas. Many factors are associated with VBDS including infections, neoplasms, and drugs. Antibiotic is one of the most frequently reported causes of VBDS. PATIENT CONCERNS A 29-year-old female was admitted because of liver injury for over 3 months. Tests for viruses that can cause hepatitis and autoantibodies were all negative. She was prescribed with antibiotics approximately a week before liver injury while there was no history of alcohol consumption. DIAGNOSES Liver biopsy demonstrated a loss of intrahepatic bile duct in most of the portal tracts. INTERVENTIONS This patient was treated with ursodeoxycholic acid, polyene phosphatidylcholine, and bicyclol. Most importantly, the treatments in our hospital were proved by the ethics committee of Department of Infectious Disease, Anhui Provincial Hospital. OUTCOMES The symptoms were improved. She is still under treatment. LESSONS VBDS is rare but can be severe. A liver biopsy offers an important evidence for the diagnosis of VBDS, especially for those with a history of susceptible drugs taking.
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Affiliation(s)
- Zonghao Zhao
- Department of Infectious Disease, Third Liver Unit
| | - Lei Bao
- Department of Infectious Disease, Third Liver Unit
| | - Xiaolan Yu
- Department of Ear-Nose-Throat, Anhui Provincial Hospital, Anhui Medical University, Hefei
| | - Chuanlong Zhu
- Department of Infectious Disease, Jiangsu Provincial Hospital, Nanjing Medical University, Nanjing
| | - Jing Xu
- Department of Infectious Disease, Third Liver Unit
| | - Yu Wang
- Department of Infectious Disease, Third Liver Unit
| | - Ming Yin
- Department of Infectious Disease, Intensive Care Unit, Anhui Provincial Hospital, Anhui Medical University, Hefei, China
| | - Yi Li
- Department of Infectious Disease, Third Liver Unit
| | - Wenting Li
- Department of Infectious Disease, Third Liver Unit
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9
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Chen F, Tu XL. Revaluation of vanishing bile duct syndrome. Shijie Huaren Xiaohua Zazhi 2016; 24:3445-3453. [DOI: 10.11569/wcjd.v24.i23.3445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Vanishing bile duct syndrome (VBDS) can result from multiple etiologies, including congenital and genetic diseases, ischemic causes, neoplastic disorders, infections, immune disorders, drugs, idiopathic adulthood ductopenia (IAD) and so on. Recently, lymphoma, HIV/AIDS and drugs were identified to be major etiologies in the reported cases, some of which presented complex clinical course and were contributed by more than one etiological factor. Hepatic biopsy must be done for the diagnosis of VBDS and immunohistochemical staining for cytokeratin 7 (CK7) and CK19 has contributed to the establishment of diagnosis of VBDS. VBDS can be usually treated with symptomatic and supportive therapy, etiological therapy, liver transplantation, ursodeoxycholic acid and immunosuppressive agents. Glucocorticoids can be tried to switch to mycophemolate mofeil or tacrolimus when their effects are poor or side effects are severe. Severe cases ought to receive multimodality therapy besides plasmapheresis.
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Mason M, Adeyi O, Fung S, Millar BA. Vanishing bile duct syndrome in the context of concurrent temozolomide for glioblastoma. BMJ Case Rep 2014; 2014:bcr-2014-208117. [PMID: 25432915 DOI: 10.1136/bcr-2014-208117] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Temozolomide, an oral alkylating agent, is used in the treatment of glioblastoma. We describe a case of a 62-year-old woman developing jaundice with significant derangement of liver function tests on day 17 of focal radiotherapy with concomitant temozolomide. There was no structural abnormality on imaging and liver biopsy was performed. Pathology revealed absence of small terminal bile ducts affecting up to 60% of sampled portal tracts and senescence of many of the remaining small bile ducts, in keeping with a diagnosis of acute vanishing bile duct syndrome. This is a rare syndrome. It has been documented in association with Hodgkin's lymphoma and viral causes. Drugs implicated as precipitating this condition include antiseizure medications, some antibiotics, ibuprofen and antifungals. Temozolomide was stopped. The patient received supportive care, ursodeoxycholic acid 750 mg daily and cholestyramine 4 g twice daily. She was otherwise asymptomatic and her blood results returned to normal by day 129.
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Affiliation(s)
- Matthew Mason
- Department of Radiation Oncology, University of Toronto, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Oyedele Adeyi
- Department of Pathology, University of Toronto, Toronto, Ontario, Canada
| | - Scott Fung
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Barbara-Ann Millar
- Department of Radiation Oncology, University of Toronto, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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Abstract
Viruses other than the classic hepatotropic viruses, hepatitis A through E, may cause hepatic injury [1]. Among these are Epstein–Barr virus (EBV), cytomegalovirus (CMV), herpes simplex virus (HSV), varicella zoster virus (VZV), human herpes viruses (HHV) 6, 7, and 8, human parvovirus B19, and adenoviruses (Table 11.1). The clinical presentation of infections with these viruses may be indistinguishable from that associated with infection with classic hepatotropic viruses. The presentation ranges from mild and transient elevation of aminotransferases to acute hepatitis and can also lead to acute liver failure [1]. These viruses should be considered as possible etiologic agents in patients who have acute liver injury and whose serologic markers for the classic hepatotropic viruses are not indicative of an active infection [1]. In the present chapter, we review the clinical manifestations and the potential for immune-mediated liver injury associated with several of these viruses (see summary Table 11.2).
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Affiliation(s)
- M. Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California School of Medicine, Davis, California USA
| | - John M. Vierling
- Medicine and Surgery, Baylor College of Medicine, Houston, Texas USA
| | - Michael P. Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Medical School of Hannover, Germany
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12
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Oppenheimer AP, Koh C, McLaughlin M, Williamson JC, Norton TD, Laudadio J, Heller T, Kleiner DE, High KP, Morse CG. Vanishing bile duct syndrome in human immunodeficiency virus infected adults: A report of two cases. World J Gastroenterol 2013; 19:115-21. [PMID: 23326172 PMCID: PMC3542762 DOI: 10.3748/wjg.v19.i1.115] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 07/02/2012] [Accepted: 08/03/2012] [Indexed: 02/06/2023] Open
Abstract
Vanishing bile duct syndrome (VBDS) is a group of rare disorders characterized by ductopenia, the progressive destruction and disappearance of intrahepatic bile ducts leading to cholestasis. Described in association with medications, autoimmune disorders, cancer, transplantation, and infections, the specific mechanisms of disease are not known. To date, only 4 cases of VBDS have been reported in human immunodeficiency virus (HIV) infected patients. We report 2 additional cases of HIV-associated VBDS and review the features common to the HIV-associated cases. Presentation includes hyperbilirubinemia, normal liver imaging, and negative viral and autoimmune hepatitis studies. In HIV-infected subjects, VBDS occurred at a range of CD4+ T-cell counts, in some cases following initiation or change in antiretroviral therapy. Lymphoma was associated with two cases; nevirapine, antibiotics, and viral co-infection were suggested as etiologies in the other cases. In HIV-positive patients with progressive cholestasis, early identification of VBDS and referral for transplantation may improve outcomes.
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Spivack T, Chawla R, Marik PE. Epstein-Barr virus-associated hemophagocytic syndrome mimicking severe sepsis. J Emerg Trauma Shock 2011; 1:119-22. [PMID: 19561991 PMCID: PMC2700613 DOI: 10.4103/0974-2700.43198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2008] [Accepted: 07/27/2008] [Indexed: 11/27/2022] Open
Abstract
Severe sepsis is amongst the most common reasons for admission to the intensive care unit (ICU) throughout the world and is a common cause of death. The diagnosis of sepsis is usually straightforward, being based on a constellation of clinical and laboratory features. Noninfectious disorders, including pancreatitis, drug reactions, and autoimmune disorders, may cause a systemic inflammatory response that mimics sepsis. We present the case of a 32-year-old male with Epstein-Barr virus-associated hemophagocytic syndrome who presented to the ICU with features of severe sepsis which progressed to multisystem organ failure and death despite aggressive supportive measures.
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Okabe T, Shah G, Mendoza V, Hirani A, Baram M, Marik P. What intensivists need to know about hemophagocytic syndrome: an underrecognized cause of death in adult intensive care units. J Intensive Care Med 2011; 27:58-64. [PMID: 21257627 DOI: 10.1177/0885066610393462] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hemophagocytic syndrome, also known as hemophagocytic lymphohistiocytosis (HLH), is a rare and frequently fatal disorder caused by an uncontrollable and ineffective systemic immune response. Patients initially present with fever, cytopenia, and hepatosplenomegaly, and subsequently develop multiorgan failure (MOF). Hemophagocytosis can be found on biopsy specimen but is not required. Acquired forms of HLH can occur in apparently healthy adults, while children present more often with an inherited form of the disease. Since HLH often presents with sepsis-like symptoms and organ dysfunction, patients are usually treated for presumed sepsis, which inevitably leads to delayed diagnosis and treatment. Intensivists need to have a low threshold for suspecting this disorder when previously healthy individuals present with a fulminant sepsis-like syndrome, which are unresponsive to conventional treatment. We present 3 patients with HLH who were admitted to our adult medical intensive care unit (MICU) over a 2-year period with fatal outcomes and emphasize the diagnostic importance of markedly elevated serum ferritin levels and the need for tissue biopsy in making an accurate diagnosis in a timely manner.
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Affiliation(s)
- Toshimasa Okabe
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA
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15
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Abstract
The Epstein-Barr virus (EBV) has an important and multifaceted role in liver pathology. As a member of the herpes virus family, EBV establishes a persistent infection in more than 90% of adults. Besides acute hepatitis during primary infection, many clinical syndromes of interest for the hepatologist are associated with EBV infection. The role of EBV in the evolution of chronic hepatitis from hepatotropic viruses is considered. Chronic EBV-associated hepatitis is suspected in immunocompetent adults with compatible serology, suggestive histology and detection of the viral genome in the liver and/or increase of specific circulating cytotoxic T-lymphocytes. EBV is the main cause of post-transplant lymphoproliferative disorders which occur in up to 30% of cases. EBV-driven lymphoproliferative diseases are also recognized in non-immunocompromised patients and liver is involved in up to a third of the cases. Directly implicated in the pathogenesis of different tumors, EBV has a disputable role in hepatocellular carcinoma carcinogenesis. Further research is required in order to establish or reject the role of EBV in human liver cancer. This paper attempts to discuss the range of EBV-associated chronic liver diseases in immunocompetent patients, from mild, self-limiting mononuclear hepatitis to liver cancer.
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Yoon JY, Min SY, Park JY, Hong SG, Park SJ, Paik SY, Park YM. [A case of allopurinol-induced granulomatous hepatitis with ductopenia and cholestasis]. THE KOREAN JOURNAL OF HEPATOLOGY 2008; 14:97-101. [PMID: 18367862 DOI: 10.3350/kjhep.2008.14.1.97] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Allopurinol-induced hypersensitivity syndrome is characterized by an idiosyncratic reaction involving multiple-organs, which usually begins 2 to 6 weeks after starting allopurinol. In rare cases, the adverse reactions to allopurinol are accompanied by a variety of liver injury, such as reactive hepatitis, granulomatous hepatitis, vanishing bile duct syndrome, or fulminant hepatic failure. Here we report a case with granulomatous hepatitis and ductopenia. A 69-year-old man with chronic renal failure, hyperuricemia, and previously normal liver function presented with jaundice, skin rash, and fever 2 weeks after taking allopurinol (200 mg/day). In histopathology, a liver biopsy specimen showed mild spotty necrosis of hepatocytes, marked cholestasis in parenchyma, and some granulomas in the portal area. There were vacuolar degeneration in the interlobular bile ducts and ductopenia in the portal tracts. Pathologic criteria strongly suggested the presence of allopurinol-induced granulomatous hepatitis with ductopenia and cholestasis. The patient fully recovered following the early administration of systemic corticosteroid therapy.
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Affiliation(s)
- Jae Young Yoon
- Department of Internal Medicine, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
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Abstract
This is the first description in which the diagnosis of vanishing bile duct syndrome (VBDS) preceded the diagnosis of Hodgkin disease (HD) by several months, and for which patients received modifications to modern MOPP-ABV chemotherapy with successful clinical remission. VBDS is an uncommon form of liver disease manifested by severe cholestasis and progressive liver failure. We report 2 cases of stage IIIB pediatric HD and VBDS. Because VBDS is progressive and the only curative treatment is liver transplant, it is imperative to recognize that children with VBDS may also have concurrent HD.
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Abstract
Perhaps no condition associated with chronic cholestasis is less understood than vanishing bile duct syndrome, a term that refers loosely to the group of acquired disorders associated with progressive destruction and disappearance of the intrahepatic bile ducts and, ultimately, cholestasis. Although the array of insults resulting in poor bile flow is vast, most adult patients who have chronic cholestasis have either primary biliary cirrhosis (or primary sclerosing cholangitis; in some cases, however, a cause cannot be identified. This article reviews the multiple causes, postulated pathophysiology, clinical features, and treatment options for this syndrome.
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Affiliation(s)
- Nancy S Reau
- Center for Liver Diseases, Section of Gastroenterology, Department of Medicine, University of Chicago Medical Center, 5841 S. Maryland, MC7120, Chicago, IL 60637, USA.
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Severe jaundice, due to vanishing bile duct syndrome, as presenting symptom of Hodgkin's lymphoma, fully reversible after chemotherapy. Eur J Gastroenterol Hepatol 2008; 20:145-7. [PMID: 18188038 DOI: 10.1097/meg.0b013e3282b9e6c2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Liver involvement in Hodgkin's lymphoma is common and is caused by hepatic infiltration, biliary obstruction by lymphoma, hepatitis, sepsis or complications of chemotherapeutic treatment. Jaundice caused by the vanishing bile duct syndrome related to Hodgkin's lymphoma is very rare. The mechanism is poorly understood but a paraneoplastic effect seems most likely as liver biopsy samples show cholestasis in the absence of lymphoma cells. Despite adequate treatment almost all reported patients died of liver failure or disease progression. Disease progression is explained partly by the difficulties encountered in the administration of potential hepatotoxic chemotherapy in severely cholestatic patients. We describe a 17-year-old man with vanishing bile duct syndrome and Hodgkin's lymphoma who was treated successfully with chemotherapy. The markedly elevated serum bilirubin levels completely normalized. Our case demonstrates that although dosing of chemotherapy in this situation can be very difficult, a good clinical outcome is possible, which makes the attempt at curative treatment worthwhile.
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Hindupur S, Yeung M, Shroff P, Fritz J, Kirmani N. Vanishing bile duct syndrome in a patient with advanced AIDS. HIV Med 2007; 8:70-2. [PMID: 17305935 DOI: 10.1111/j.1468-1293.2007.00415.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A 39-year-old HIV-infected woman developed signs and symptoms of obstructive jaundice and cholestasis. Serological tests were positive for cytomegalovirus (CMV) infection. There was no evidence of AIDS cholangiopathy in ultrasonography or magnetic resonance cholangiopancreatography (MRCP). A liver biopsy revealed marked ductopenia and the patient was diagnosed with vanishing bile duct syndrome, thought to be secondary to CMV infection as a result of profound immunosuppression. To the best of our knowledge, this is the first reported case of vanishing bile duct syndrome diagnosed in a patient with HIV/AIDS.
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Affiliation(s)
- S Hindupur
- Department of Internal Medicine, Washington University School of Medicine, Saint Louis, MO 63110, USA.
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Larroche C, Ziol M, Zidi S, Dhote R, Roulot D. Atteinte hépatique au cours du syndrome d’activation macrophagique. ACTA ACUST UNITED AC 2007; 31:959-66. [DOI: 10.1016/s0399-8320(07)78305-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Song KS, Sung HJ. Effect of plasma exchange on the circulating IL-6 levels in a patient with fatal hemophagocytic syndrome associated with bile ductopenia. Ther Apher Dial 2006; 10:87-9. [PMID: 16556142 DOI: 10.1111/j.1744-9987.2006.00347.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report here the case of a patient suffering from hemophagocytic syndrome (HPS) associated with bile ductopenia. A 24-year old man was admitted after suffering fever, sore throat and general malaise for 7 days and jaundice for 2 days. Clinical studies showed hepatic dysfunction with hyperbilirubinemia. Epstein-Barr viral DNA from two bone marrow samples was detected. Bone marrow aspiration disclosed findings of HPS. Liver biopsy showed centrilobular cholestasis with lack of interlobular bile duct. Repeated therapeutic plasma exchange was effective for decreasing serum bilirubin and interleukin-6 levels. The patient received liver transplantation, however, he finally died of alveolar hemorrhage resulting from disseminated intravascular coagulation and acute rejection.
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Affiliation(s)
- Kyung Soon Song
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea.
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Bihl F, Emmenegger U, Reichen J, Neftel KA, Zimmermann A, Cerny A. Macrophage activating syndrome is associated with lobular hepatitis and severe bile duct injury with cholestasis. J Hepatol 2006; 44:1208-12. [PMID: 16618513 DOI: 10.1016/j.jhep.2006.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2005] [Revised: 03/02/2006] [Accepted: 03/12/2006] [Indexed: 12/04/2022]
Abstract
Macrophage activating syndrome (MAS) is a rare hematological disorder associated with uncontrolled systemic T-cell activation. Persistent fever, fatigue and hepatosplenomegaly are frequent clinical manifestations, whereas hyperferritinemia, elevated serum lactate dehydrogenase levels and cytopenia are key criteria for the diagnosis of MAS. The nature of liver pathology in MAS has been partially elucidated but destructive biliary lesions have been rarely described. This report illustrates four cases of MAS developing marked cholestasis, leading to one case of biliary cirrhosis necessitating liver transplantation. Histologically, liver involvement was characterized in all cases by acute lobular hepatitis, marked hepatocyte apoptosis and small bile duct injury similar to the vanishing bile duct syndrome. Immuno-histological studies showed that the inflammatory changes and bile duct lesions were dominated by the presence of activated macrophages and T-cells, in particular CD8+ lymphocytes, and in part NK-cells. These findings suggest that in MAS, various T-cell triggers such as infection, autoimmune disease and malignancy might result in the release of cytokines, which in turn activate macrophages to trigger a systemic acute phase response and local tissue damage. This communication suggests that a macrophage, T- and NK-cell network is operational in the pathogenesis of the cholangiocyte, hepatocyte and sinus endothelial cell damage in MAS.
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Affiliation(s)
- Florian Bihl
- Department of Internal Medicine, Ospedale Civico, 6900 Lugano, Switzerland, and Women's College Health Sciences Centre, Toronto, Ont., Canada
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Drebber U, Kasper HU, Krupacz J, Haferkamp K, Kern MA, Steffen HM, Quasdorff M, Zur Hausen A, Odenthal M, Dienes HP. The role of Epstein-Barr virus in acute and chronic hepatitis. J Hepatol 2006; 44:879-85. [PMID: 16554102 DOI: 10.1016/j.jhep.2006.02.006] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2005] [Revised: 01/27/2006] [Accepted: 02/01/2006] [Indexed: 12/13/2022]
Abstract
BACKGROUND/AIMS Epstein-Barr virus has a seroprevalence of more than 80% world wide and is known to be associated with hepatitis. However, little is known about the underlying pathogenesis and immunmechanisms and no standard diagnostic criteria to diagnose EBV-hepatitis are available. METHODS We collected liver biopsies (n=21) with the tentative diagnosis of EBV induced hepatitis according to pathological changes and traceable EBV genome by PCR. Correlation with serological data revealed acute in seven cases, convalescent in two cases, past EBV infection in six cases. Viral RNA was visualised by in situ hybridisation within nuclei of lymphocytes. RESULTS In seven of 68 liver biopsies with the diagnosis 'liver disease of unknown aetiology' EBV genome in the tissue was demonstrated indicating a possible role for EBV in the induction of hepatitis or a trapping of infected lymphocytes within the liver. In a control group of 20 EBV-seropositive patients with steatohepatitis EBV-DNA PCR of the liver tissue was negative. Immunohistochemistry identified CD3 and CD8 positive T-lymphocytes as the main lymphocytic infiltrate in EBV hepatitis. CONCLUSIONS EBV hepatitis should be taken into consideration in case of typical histopathological changes and a positive DNA PCR of liver biopsy. Serological confirmation of the diagnosis is inevitable.
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Affiliation(s)
- Uta Drebber
- Institute of Pathology, University of Cologne, Cologne, Germany.
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Chiba T, Goto S, Yokosuka O, Imazeki F, Tanaka M, Fukai K, Takahashi Y, Tsujimura H, Saisho H. Fatal chronic active Epstein-Barr virus infection mimicking autoimmune hepatitis. Eur J Gastroenterol Hepatol 2004; 16:225-8. [PMID: 15075999 DOI: 10.1097/00042737-200402000-00017] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
We report a 22-year-old female who presented with pyrexia, pancytopenia and liver dysfunction. The patient showed mild liver dysfunction with low-grade fever and mild hepatosplenomegaly 6 years previously, and autoimmune hepatitis (AIH) was diagnosed based on the examination of the laboratory data and liver biopsy. On admission, both markers of Epstein-Barr virus (EBV) and in-situ hybridisation from a liver biopsy specimen indicated chronic active EBV infection (CAEBV). The patient was administered an immunosuppressive agent and antiviral drug added to steroid therapy, but ultimately died from liver failure and virus-associated haemophagocytosis 10 months after the definite diagnosis. Retrospective examination of the serum at the diagnosis of AIH revealed extremely high titres of antibody to EBV, and EBV-DNA was also detectable by polymerase chain reaction. These results suggest the possibility that the patient may already have suffered from CAEBV at the initial diagnosis. We presume that hepatic involvement of CAEBV should be considered as differential diagnosis in cases showing liver dysfunction with clinical and biochemical features observed in AIH.
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Affiliation(s)
- Tetsuhiro Chiba
- Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Chuo Ward, Chiba, Japan
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Lefkowitch JH. Pathology of the liver. Curr Opin Gastroenterol 2001; 17:197-204. [PMID: 17031160 DOI: 10.1097/00001574-200105000-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Traditional anatomic pathology studies and molecular investigations both contributed to the breadth of current information in the field of liver pathology this year. Techniques such as reverse transcription polymerase chain reaction can identify recurrence of hepatitis C virus infection in the liver as early as 5 days after transplantation. Chronic rejection after transplantation may be characterized not only by ductopenia but also by loss of portal tract hepatic artery branches. There are many diseases of small bile ducts in adults, and idiopathic adulthood ductopenia has been identified in extended family members. Adverse reactions to drugs may precipitate their removal from the pharmacopoeia, such as the many cases reported of severe bridging and submassive necrosis due to troglitazone (a thiazolidinedione antidiabetic agent). Several publications highlighted the association of hepatitis C virus infection with lymphoproliferative diseases and, newly, with cholangiocarcinoma.
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Affiliation(s)
- J H Lefkowitch
- College of Physicians and Surgeons of Columbia University, New York, New York 10032, USA.
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Abstract
New insights into the regulation of hepatobiliary transport proteins have provided the basis for a better understanding of the pathogenesis of cholestatic liver diseases. Mutations of transporter genes can cause hereditary cholestatic syndromes, the study of which has shed much light on the basic mechanisms of bile secretion and cholestasis. Important new studies have been published about the pathogenesis, clinical features, and treatment of primary biliary cirrhosis, primary sclerosing cholangitis, cholestasis of pregnancy, total parenteral nutrition-induced cholestasis, and drug-induced cholestasis.
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Affiliation(s)
- M Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Karl Franzens University School of Medicine, Graz, Austria
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