1
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Flerova E, Ambilil M, Civan JM, Sass DA, Maley WR, Pulinthanathu R, Huang J. Striking Cholestatic Giant Cell Hepatitis Resulting in Fulminant Liver Failure After Garcinia Cambogia Use. Int J Surg Pathol 2024; 32:619-624. [PMID: 37461217 DOI: 10.1177/10668969231186926] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
Garcinia cambogia, a weight control herbal, can cause mild liver toxicity with nonspecific histologic changes. Herein, we reported a case of herbal-induced fulminant cholestatic giant cell hepatitis due to garcinia cambogia use. A 65-year-old woman with breast cancer treated 18 years earlier was admitted for obstructive jaundice for 2 weeks. She started using garcinia cambogia 3 months ago for weight loss. Physical exam showed scleral icterus. Serum studies excluded Wilson's disease, systemic infection including COVID-19 (coronavirus disease 2019), autoimmune hepatitis, and metabolic or toxicologic causes. An urgent liver biopsy showed severe giant cell hepatitis in absence of HSV-1/2, cytomegalovirus, HBsAg and HBcAg (immunostain), and EBV (in situ hybridization). Despite supportive therapy, the patient developed grade 2-3 hepatic encephalopathy and necessitated liver transplant. The explanted liver was markedly atrophy, in which the most striking histologic finding was diffuse distribution of multinucleated giant hepatocytes with syncytial pattern in a background of extensive zone-1 accentuated, geographic, hemorrhagic, confluent hepatocytic necrosis, along with remarkable hepatocytic and canalicular cholestasis. Marked hepatocellular and sinusoidal iron orverload present. The patient recovered uneventfully.
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Affiliation(s)
- Elizaveta Flerova
- Department of Pathology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Manju Ambilil
- Department of Pathology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jesse M Civan
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - David A Sass
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Warren R Maley
- Division of Transplant Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rajiv Pulinthanathu
- Department of Pathology, Cooperman Saint Barnabas Medical Center, Livingston, NJ, USA
| | - Jialing Huang
- Department of Pathology, Geisinger Medical Center, Danville, PA, USA
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2
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Jager MC, Choi E, Tomlinson JE, Van de Walle G. Naturally acquired equine parvovirus-hepatitis is associated with a wide range of hepatic lesions in horses. Vet Pathol 2024; 61:442-452. [PMID: 38018088 PMCID: PMC11068485 DOI: 10.1177/03009858231214024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
Equine parvovirus-hepatitis (EqPV-H) is the causative agent of Theiler's disease, or severe acute hepatic necrosis, in horses. However, it is poorly understood whether EqPV-H is associated with other histologic findings in horses with clinical liver disease. The objective of this study was to examine the prevalence and severity of EqPV-H infections in diagnostic liver samples. Archived formalin-fixed, paraffin-embedded (FFPE) liver samples (n = 98) from Cornell University and University of California, Davis, collected between 2007 and 2022 were evaluated for 15 individual histologic features and by EqPV-H in situ hybridization. EqPV-H was detected in 48% (n = 47) of samples. The most common histologic features of EqPV-H-positive samples included individual hepatocyte death (n = 40, 85%), lobular infiltrates (n = 38, 80%), portal infiltrates (n = 35, 74%), and ductular reaction (n = 33, 70%). Centrilobular necrosis, portal infiltrate, and individual hepatocyte death were positively associated with high viral load. Neutrophil infiltrates, bridging fibrosis, and portal edema were negatively associated with a high viral load. Only 4 of 49 tested samples were positive for equine hepacivirus by polymerase chain reaction (PCR), but the PCR assay was unreliable for FFPE tissues. In summary, this study demonstrates that EqPV-H is common in a variety of liver pathologies and should be considered as a differential diagnosis in cases of hepatitis other than Theiler's disease.
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Affiliation(s)
| | - Eunju Choi
- University of California, Davis, Davis, CA
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3
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Jiao J, Chezar K, Zhang X, Wang D, Cao W, Bindu C, Chen W, Neto AG, Henn P, Riahi I, Wang HL, Papke DJ, Zhao L, Xue Y, Liao X, Zhang X. Postinfantile Giant Cell Hepatitis in Native and Allograft Livers: A Multi-Institutional Clinicopathologic Study of 70 Cases. Mod Pathol 2023; 36:100298. [PMID: 37544363 DOI: 10.1016/j.modpat.2023.100298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 06/16/2023] [Accepted: 07/28/2023] [Indexed: 08/08/2023]
Abstract
Postinfantile giant cell hepatitis (PIGCH) is a rare hepatitis pattern in adults with variable etiologies and clinical outcomes. We conducted a multi-institutional retrospective study to define the clinicopathologic characteristics of patients with PIGCH. A total of 70 PIGCH cases were identified and reviewed for pathological features, including fibrosis, cholestasis, inflammation, steatosis, necrosis, and apoptosis, as well as the distribution of giant cells and the maximum number of giant cells per high-power field. Demographic and clinical data, including age, sex, laboratory results, etiologies, and follow-up results, were recorded. Among the 70 cases, 40% (28/70) were associated with autoimmune liver diseases, followed by 9 (13%) with unknown etiology, 8 (11%) with viral infection, 5 (7%) with medications, 5 with combined etiologies, and 4 (6%) with malignancies (mostly chronic lymphocytic leukemia). Notably, another 16% were de novo PIGCH in liver allografts, most of which occurred after a rejection event. During follow-up, 26 (37%) patients died of the disease and 44 (63%) were alive. Deceased patients were characterized by older age (mean age, 54.9 vs 45.5 years; P = .02), higher alkaline phosphatase level (mean value, 253.3U/L vs 166.3 U/L; P = .03), higher fibrosis stage (stage 3-4 vs stage 0-2, 57.7% vs 29.6%; P = .03), being more likely to have de novo PIGCH after transplantation (23.1% vs 11.4%; P = .04), and being less likely to have primary autoimmune liver disease etiology (26.9% vs 47.7%; P = .04). These results indicate that PIGCH is a rare pattern of liver injury associated with different etiologies and variable clinical outcomes. Autoimmune liver disease with PIGCH is associated with better survival, whereas de novo PIGCH in allografts is associated with poorer survival. Older age, higher alkaline phosphatase level, and advanced fibrosis are adverse prognostic factors.
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Affiliation(s)
- Jingjing Jiao
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Ksenia Chezar
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Xuefeng Zhang
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Donghai Wang
- Department of Pathology, New York University Langone Health, New York, New York
| | - Wenqing Cao
- Department of Pathology, New York University Langone Health, New York, New York
| | - Challa Bindu
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Wei Chen
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Antonio Galvao Neto
- Department of Pathology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Patrick Henn
- Department of Pathology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Irene Riahi
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Hanlin L Wang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - David J Papke
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lei Zhao
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Yue Xue
- Department of Laboratory Medicine and Pathology, Northwestern University, Chicago, Illinois
| | - Xiaoyan Liao
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
| | - Xuchen Zhang
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut.
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4
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Almaas R, Atneosen-Åsegg M, Ytre-Arne ME, Melheim M, Sorte HS, Cízková D, Reims HM, Bezrouk A, Harrison SP, Strand J, Hermansen JU, Andersen SS, Eiklid KL, Mokrý J, Sullivan GJ, Stray-Pedersen A. Aagenaes syndrome/lymphedema cholestasis syndrome 1 is caused by a founder variant in the 5'-untranslated region of UNC45A. J Hepatol 2023; 79:945-954. [PMID: 37328071 DOI: 10.1016/j.jhep.2023.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 05/12/2023] [Accepted: 05/21/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND & AIMS Lymphedema cholestasis syndrome 1 or Aagenaes syndrome is a condition characterized by neonatal cholestasis, lymphedema, and giant cell hepatitis. The genetic background of this autosomal recessive disease was unknown up to now. METHODS A total of 26 patients with Aagenaes syndrome and 17 parents were investigated with whole-genome sequencing and/or Sanger sequencing. PCR and western blot analyses were used to assess levels of mRNA and protein, respectively. CRISPR/Cas9 was used to generate the variant in HEK293T cells. Light microscopy, transmission electron microscopy and immunohistochemistry for biliary transport proteins were performed in liver biopsies. RESULTS One specific variant (c.-98G>T) in the 5'-untranslated region of Unc-45 myosin chaperone A (UNC45A) was identified in all tested patients with Aagenaes syndrome. Nineteen were homozygous for the c.-98G>T variant and seven were compound heterozygous for the variant in the 5'-untranslated region and an exonic loss-of-function variant in UNC45A. Patients with Aagenaes syndrome exhibited lower expression of UNC45A mRNA and protein than controls, and this was reproduced in a CRISPR/Cas9-created cell model. Liver biopsies from the neonatal period demonstrated cholestasis, paucity of bile ducts and pronounced formation of multinucleated giant cells. Immunohistochemistry revealed mislocalization of the hepatobiliary transport proteins BSEP (bile salt export pump) and MRP2 (multidrug resistance-associated protein 2). CONCLUSIONS c.-98G>T in the 5'-untranslated region of UNC45A is the causative genetic variant in Aagenaes syndrome. IMPACT AND IMPLICATIONS The genetic background of Aagenaes syndrome, a disease presenting with cholestasis and lymphedema in childhood, was unknown until now. A variant in the 5'-untranslated region of the Unc-45 myosin chaperone A (UNC45A) was identified in all tested patients with Aagenaes syndrome, providing evidence of the genetic background of the disease. Identification of the genetic background provides a tool for diagnosis of patients with Aagenaes syndrome before lymphedema is evident.
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Affiliation(s)
- Runar Almaas
- Department of Pediatric Research, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Pb 4950, Nydalen, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Paediatrics, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Pb 4950, Nydalen, Oslo, Norway; European Reference Network - Rare Liver.
| | | | - Mari Eknes Ytre-Arne
- Norwegian National Unit for Newborn Screening, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Maria Melheim
- Department of Pediatric Research, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Pb 4950, Nydalen, Oslo, Norway; European Reference Network - Rare Liver
| | - Hanne Sørmo Sorte
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway
| | - Dana Cízková
- Department of Histology and Embryology, Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Henrik Mikael Reims
- European Reference Network - Rare Liver; Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Aleš Bezrouk
- Department of Medical Biophysics, Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Sean Philip Harrison
- Department of Pediatric Research, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Pb 4950, Nydalen, Oslo, Norway; European Reference Network - Rare Liver
| | - Janne Strand
- Norwegian National Unit for Newborn Screening, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Johanne Uthus Hermansen
- Department of Pediatric Research, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Pb 4950, Nydalen, Oslo, Norway
| | - Sofie Strøm Andersen
- Department of Pediatric Research, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Pb 4950, Nydalen, Oslo, Norway
| | | | - Jaroslav Mokrý
- Department of Histology and Embryology, Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Gareth John Sullivan
- Department of Pediatric Research, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Pb 4950, Nydalen, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway; European Reference Network - Rare Liver
| | - Asbjørg Stray-Pedersen
- European Reference Network - Rare Liver; Norwegian National Unit for Newborn Screening, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
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5
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Jiao J, Zhang X. Post-infantile Giant Cell Hepatitis: A Literature Review and Meta-analysis. JOURNAL OF CLINICAL AND TRANSLATIONAL PATHOLOGY 2022; 2:100-107. [PMID: 37092012 PMCID: PMC10117396 DOI: 10.14218/jctp.2022.00016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Post-infantile giant cell hepatitis (PIGCH) is a rare disease entity in adults with a multifactorial etiology and widely variable clinical courses and outcomes. The factors associated with the worse outcomes of this disease entity are still unclear. We identified 68 PIGCH patients by searching PubMed and performed meta-analysis. Among the 68 patients, 32% of the cases were associated with autoimmune disorders, followed by 21% associated with viral infections, 10% with medication, and 7% with malignancy. Twenty-four percent of the patients had more than one etiological factor, and 6% had other uncommon etiologies or an etiology that could not be identified. At the time of this report, 17 patients had died of the disease (poor outcome), and 51 patients remained alive with the disease (good outcome). Compared to the patients with a good outcome, the patients with a poor outcome were characterized by older age, lower levels of platelets and albumin, higher level of total bilirubin, and a diffuse distribution pattern of giant cells in the liver. There were no differences in gender distribution, aminotransferase, alkaline phosphatase, gamma-glutamyl transferase, etiological distribution, or other histological features, including interface hepatitis, necrosis, lobular inflammation, portal inflammation, cholestasis, or fibrosis. Further studies would be needed to better understand the disease mechanisms and unmask any additional etiological factors and targeted therapies.
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Affiliation(s)
| | - Xuchen Zhang
- Correspondence to: Xuchen Zhang, Department of Pathology, Yale University School of Medicine, 310 Cedar Street, PO Box 208023, New Haven, CT 06510, United States. Tel: +1 203-785-6010, Fax: +1 203-737-2922,
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6
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Ritter AL, Gold J, Hayashi H, Ackermann AM, Hanke S, Skraban C, Cuddapah S, Bhoj E, Li D, Kuroda Y, Wen J, Takeda R, Bibb A, El Chehadeh S, Piton A, Ohl J, Kukolich MK, Nagasaki K, Kato K, Ogi T, Bhatti T, Russo P, Krock B, Murrell JR, Sullivan JA, Shashi V, Stong N, Hakonarson H, Sawano K, Torti E, Willaert R, Si Y, Wilcox WR, Wirgenes KV, Thomassen K, Carlotti K, Erwin A, Lazier J, Marquardt T, He M, Edmondson AC, Izumi K. Expanding the phenotypic spectrum of ARCN1-related syndrome. Genet Med 2022; 24:1227-1237. [PMID: 35300924 PMCID: PMC9923403 DOI: 10.1016/j.gim.2022.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 01/18/2023] Open
Abstract
PURPOSE This study aimed to describe the phenotypic and molecular characteristics of ARCN1-related syndrome. METHODS Patients with ARCN1 variants were identified, and clinician researchers were connected using GeneMatcher and physician referrals. Clinical histories were collected from each patient. RESULTS In total, we identified 14 cases of ARCN1-related syndrome, (9 pediatrics, and 5 fetal cases from 3 families). The clinical features these newly identified cases were compared to 6 previously reported cases for a total of 20 cases. Intrauterine growth restriction, micrognathia, and short stature were present in all patients. Other common features included prematurity (11/15, 73.3%), developmental delay (10/14, 71.4%), genitourinary malformations in males (6/8, 75%), and microcephaly (12/15, 80%). Novel features of ARCN1-related syndrome included transient liver dysfunction and specific glycosylation abnormalities during illness, giant cell hepatitis, hepatoblastoma, cataracts, and lethal skeletal manifestations. Developmental delay was seen in 73% of patients, but only 3 patients had intellectual disability, which is less common than previously reported. CONCLUSION ARCN1-related syndrome presents with a wide clinical spectrum ranging from a severe embryonic lethal syndrome to a mild syndrome with intrauterine growth restriction, micrognathia, and short stature without intellectual disability. Patients with ARCN1-related syndrome should be monitored for liver dysfunction during illness, cataracts, and hepatoblastoma. Additional research to further define the phenotypic spectrum and possible genotype-phenotype correlations are required.
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Affiliation(s)
- Alyssa L Ritter
- Division of Human Genetics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jessica Gold
- Division of Human Genetics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hiroshi Hayashi
- Division of Human Genetics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Amanda M Ackermann
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Stephanie Hanke
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Cara Skraban
- Division of Human Genetics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sanmati Cuddapah
- Division of Human Genetics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Elizabeth Bhoj
- Division of Human Genetics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Dong Li
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Yukiko Kuroda
- Division of Human Genetics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jessica Wen
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ryojun Takeda
- Division of Genetics, Nagano Children's Hospital, Nagano, Japan
| | - Audrey Bibb
- Department of Human Genetics, Emory University School of Medicine, Emory University, Atlanta, GA
| | - Salima El Chehadeh
- Service de Génétique Médicale, Institut de Génétique Médicale d'Alsace (IGMA), Hôpitaux Universitaires de Strasbourg, Strasbourg, France; Laboratoire de Génétique Médicale, UMR_S1112, Institut de Génétique Médicale d'Alsace (IGMA), Université de Strasbourg et INSERM, Strasbourg, France
| | - Amélie Piton
- Department of Translational Medicine and Neurogenetics, Institut Génétique Biologie Moléculaire Cellulaire, IGBMC - CNRS UMR 7104 - Inserm U 1258, Illkirch, France; Laboratoire de Diagnostic Génétique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Jeanine Ohl
- Service d'assistance Médicale à la Procréation, Centre médico-chirurgical et obstétrical (CMCO), Schiltigheim, France
| | - Mary K Kukolich
- Department of Genetics, Cook Children's Medical Center, Cook Children's Health Care System, Fort Worth, TX
| | - Keisuke Nagasaki
- Department of Pediatrics, Niigata University Medical & Dental Hospital, Niigata, Japan
| | - Kohji Kato
- Department of Genetics, Research Institute of Environmental Medicine, Nagoya University, Nagoya, Japan
| | - Tomoo Ogi
- Department of Genetics, Research Institute of Environmental Medicine, Nagoya University, Nagoya, Japan
| | - Tricia Bhatti
- Division of Anatomic Pathology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Pierre Russo
- Division of Anatomic Pathology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Bryan Krock
- Division of Genomic Diagnostics, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jill R Murrell
- Division of Genomic Diagnostics, Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jennifer A Sullivan
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Duke University School of Medicine, Durham, NC
| | - Vandana Shashi
- Division of Medical Genetics, Department of Pediatrics, Duke University Medical Center, Duke University School of Medicine, Durham, NC
| | - Nicholas Stong
- Institute for Genomic Medicine, Columbia University, New York, NY
| | - Hakon Hakonarson
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kentaro Sawano
- Department of Pediatrics, Niigata University Medical & Dental Hospital, Niigata, Japan
| | | | | | | | - William Ross Wilcox
- Department of Human Genetics, Emory University School of Medicine, Emory University, Atlanta, GA
| | - Katrine Verena Wirgenes
- Department of Medical Genetics, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kristian Thomassen
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Angelika Erwin
- Genomic Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Joanna Lazier
- Department of Medical Genetics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Thorsten Marquardt
- Department of Pediatrics, University Hospital of Muenster, Muenster, Germany
| | - Miao He
- Metabolic and Advanced Diagnostics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Andrew C Edmondson
- Division of Human Genetics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kosuke Izumi
- Division of Human Genetics, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA.
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7
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Hemolysis in Early Infancy: Still a Cause of Cholestatic Neonatal Giant Cell Hepatitis. Am J Surg Pathol 2021; 46:801-808. [PMID: 34856569 DOI: 10.1097/pas.0000000000001841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Before the prophylactic use of anti-D antibodies in pregnancy, hemolytic anemia of the newborn was the most common cause of hyperbilirubinemia. Nowadays, given the rarity of hemolytic anemia of the newborn, hepatobiliary abnormalities, perinatal infections, and metabolic disorders have become the most common conditions in the differential diagnosis of neonatal cholestasis. Here, we report 3 instances of cholestatic giant cell hepatitis in 3 infants who had Coombs' positive hemolysis due to ABO incompatibility in 1, Rh incompatibility in another, and combined ABO and Rh incompatibility in the third. Although rare, cholestatic neonatal giant cell hepatitis associated with hemolysis still needs to be considered in patients with neonatal cholestasis. A marked elevation of aspartate aminotransferase over alanine aminotransferase can be a helpful clue to an early diagnosis.
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8
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Poddighe D, Madiyeva A, Talipova D, Umirbekova B. Infantile giant cell hepatitis with autoimmune hemolytic anemia. World J Hepatol 2021; 13:411-420. [PMID: 33959224 PMCID: PMC8080548 DOI: 10.4254/wjh.v13.i4.411] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 01/26/2021] [Accepted: 03/09/2021] [Indexed: 02/06/2023] Open
Abstract
Giant cell hepatitis (GCH) is characterized by large and multinucleated (syncytial) hepatocytes in the context of liver inflammation. Infantile GCH is typically associated with autoimmune hemolytic anemia in the absence of any other systemic or organ-specific autoimmune comorbidity. The etiology is unknown; concomitant viral infections (as potential trigger factors) have been identified in a few patients. The pathogenesis reportedly relies upon immune-mediated/ autoimmune mechanisms. This condition should be considered in any infant developing Coombs-positive anemia; indeed, anemia usually precedes the development of hepatitis. The clinical course is usually aggressive without the appropriate immunosuppressive therapy, which may include steroids, conventional immunosuppressors (e.g., azathioprine and cyclophosphamide as first-line treatments), intravenous immunoglobulin, and biologics (rituximab). Improvements in medical management (including the availability of rituximab) have significantly reduced the mortality of this condition in the last decade.
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Affiliation(s)
- Dimitri Poddighe
- Department of Medicine, Nazarbayev University School of Medicine, Nur-Sultan 010000, Kazakhstan
- Department of Pediatrics, National Research Center for Maternal and Child Health, Nur-Sultan 010000, Kazakhstan
| | - Aidana Madiyeva
- Department of Medicine, Nazarbayev University School of Medicine, Nur-Sultan 010000, Kazakhstan
| | - Diana Talipova
- Department of Medicine, Nazarbayev University School of Medicine, Nur-Sultan 010000, Kazakhstan
| | - Balzhan Umirbekova
- Department of Pediatrics, National Research Center for Maternal and Child Health, Nur-Sultan 010000, Kazakhstan
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9
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Abstract
Intrahepatic ductular reaction is a pathologic proliferation of phenotypical biliary channels. Ductular reactions aim to restore compromised physiological function after liver injury and are one of the archetypal responses of the liver to a wide variety of etiologies, among them are parenchymal loss, biliary tract disease, neoplasms, after liver transplantation, and several pediatric liver diseases. The types and extent of ductular reactions can vary, according to the etiological insult. In this review, the authors will first consider the different mechanisms for ductular reactions and their relevance for liver regeneration. After, the authors will discuss our approach to differential diagnosis for ductular reactions in different patient groups, taking into account clinical history and potential pitfalls. The authors provide an algorithmic approach for practicing pathologists and trainees when confronted by a ductular reaction in a liver biopsy.
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10
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Chugh A, Younis M, Shah K, Hart L, Hu S, Hart J, Azzam R. Hepatic Dysfunction and Hypoglycemia in a Newborn. Clin Pediatr (Phila) 2020; 59:834-836. [PMID: 32338042 DOI: 10.1177/0009922820916896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Ankur Chugh
- Medical College of Wisconsin, Milwaukee, WI, USA
- Comer Children's Hospital, Chicago, IL, USA
| | | | | | - Lara Hart
- McGill University, Montreal, Quebec, Canada
| | - Shaomin Hu
- University of Chicago Medical Center, Chicago, IL, USA
| | - John Hart
- University of Chicago Medical Center, Chicago, IL, USA
| | - Ruba Azzam
- Comer Children's Hospital, Chicago, IL, USA
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11
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Matta B, Cabello R, Rabinovitz M, Minervini M, Malik S. Post-infantile giant cell hepatitis: A single center’s experience over 25 years. World J Hepatol 2019; 11:752-760. [PMID: 31966907 PMCID: PMC6960295 DOI: 10.4254/wjh.v11.i12.752] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 09/06/2019] [Accepted: 10/19/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Giant cell hepatitis in the adult population remains very poorly defined with only 100 case reports published in the literature over the last three decades.
AIM To present our center’s experience in an attempt to learn about the predisposing factors, outcomes and efficacy of proposed therapeutic interventions for giant cell hepatitis.
METHODS A retrospective chart review was conducted through the electronic records of the University of Pittsburgh Medical Center. We queried 36726 liver biopsy reports from January 1, 1991 to December 6, 2016. Our search yielded 50 patients who were identified as carrying a definite diagnosis of post-infantile giant cell hepatitis (PIGCH) by pathology. The data collected included demographic information, laboratory data (liver function tests, autoimmune markers) and transplant status. In order to better analyze patient characteristics and outcomes, subjects were separated into a non-transplant (native) liver group and a post-liver transplant (allograft) group.
RESULTS The incidence of PIGCH was approximately 0.14% of all biopsies queried in the 25-year period. The mean age was 48 years with 66% females. Liver function tests were classified as 38.2% cholestatic, 35.3% hepatocellular and 26.5% mixed. Autoimmune hepatitis was found to be the most prevalent predisposing factor leading to PIGCH constituting 32% of cases. Management consisted mainly of immunosuppression, viral targeted therapy, supportive care and in six cases liver transplantations.
CONCLUSION The diagnosis of PIGCH remains clinically challenging and requires a high index of suspicion as well as a thorough history, physical examination, serological workup and liver biopsy. Treatment of the underlying cause can result in clinical stability in a large number of cases.
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Affiliation(s)
- Bassem Matta
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Ricardo Cabello
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
| | - Mordechai Rabinovitz
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Marta Minervini
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Shahid Malik
- Department of Medicine, University of Pittsburgh, Division of Gastroenterology Hepatology and Nutrition, Pittsburgh, PA 15213, United States
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12
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Abstract
Navigating the complexities of interpreting a liver biopsy performed on a neonate with conjugated/direct hyperbilirubinemia can be an arduous task given these biopsies are infrequently encountered. The list of entities is long and yet there are only a few histologic patterns of liver injury. The first step for the pathologist is to determine the histologic pattern, which will guide further inquiry into the useful clinical information to have while evaluating the biopsy. Ultimately, the goal is to identify those conditions that will benefit from early intervention. We begin with a review of biliary development to help understand what findings may be physiologic versus pathologic, particularly in premature infants. Then we review eight cases that cover the three most common histologic patterns of injury in patients with neonatal cholestasis: biliary obstructive, neonatal hepatitis, and paucity of intrahepatic bile ducts. The entities that serve as prototypes for these histologic patterns are covered, including biliary atresia, idiopathic neonatal hepatitis, and Alagille syndrome, along with rarer entities that have histologic overlap. The cases with accompanying tables and algorithms are intended to help place the histologic findings in the context of the overall clinical work-up, including genetic testing.
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Affiliation(s)
- Soo-Jin Cho
- Department of Pathology, University of California San Francisco, San Francisco, CA United States
| | - Grace E Kim
- Department of Pathology, University of California San Francisco, San Francisco, CA United States.
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13
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Kwong S, Meyerson C, Zheng W, Kassardjian A, Stanzione N, Zhang K, Wang HL. Acute hepatitis and acute liver failure: Pathologic diagnosis and differential diagnosis. Semin Diagn Pathol 2019; 36:404-414. [PMID: 31405537 DOI: 10.1053/j.semdp.2019.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute hepatitis and acute liver failure are severe medical conditions that require early clinical intervention. Histopathologic findings on a liver biopsy or a liver explant may help identify the underlying etiology or provide an important direction for further clinical, laboratory and radiographical investigation. This review is divided into two main portions. The first portion concentrates on various etiologies and discusses unique histologic features that can be associated with specific etiologies. The second portion describes the general morphologic features based on which the diagnosis of acute hepatitis and acute liver failure are made. Histopathologic distinction between collapse and cirrhosis and limitations of histopathologic assessment for underlying etiologies are addressed in this portion. Another focus of this review is non-necrotic acute liver failure, which typically features diffuse microvesicular steatosis secondary to various etiologies causing mitochondrial dysfunction. Molecular testing serves an increasingly important role in the diagnosis and management of this group of disorders.
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Affiliation(s)
- Stanley Kwong
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States.
| | - Cherise Meyerson
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States
| | - Wei Zheng
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States
| | - Ari Kassardjian
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States
| | - Nicholas Stanzione
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States
| | - Kuixing Zhang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States
| | - Hanlin L Wang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States.
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14
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Rhodes JM, Schuster SJ, Furth EE, Kennard K, Nasta SD, Svoboda J, Porter DL, Mato AR. Management of giant cell hepatitis associated with chronic lymphocytic leukemia - a case series and review of the literature. Cancer Biol Ther 2019; 20:1136-1140. [PMID: 31091174 DOI: 10.1080/15384047.2019.1598763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Giant cell hepatitis (GCH) is a rare diagnosis in adults that is found in 0.25% of liver biopsies. GCH has been associated with multiple causes including drugs (6-mercaptopurine, methotrexate), toxins, viruses and autoimmune. GCH has been described in few patients with chronic lymphocytic leukemia (CLL). Here we describe three patients diagnosed with GCH thought to be related to underlying CLL and its management. All of our patients were treated with a combination of immunosuppression as well as CLL-directed therapy to address CLL and concomitant liver disease. GCH is a rare manifestation of active CLL and should be ruled out with prompt liver biopsy in patients with CLL with persistent transaminitis without another attributable cause. Prompt treatment of GCH with immunosuppression is required to prevent long-term liver toxicity. If transaminitis does not improve with immunosuppression alone, the addition of CLL directed therapy should be considered in patients who carry this diagnosis to prevent long-term liver toxicity.
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Affiliation(s)
- Joanna M Rhodes
- a Lymphoma Program, Abramson Cancer Center , University of Pennsylvania , Philadelphia , PA , USA
| | - Stephen J Schuster
- a Lymphoma Program, Abramson Cancer Center , University of Pennsylvania , Philadelphia , PA , USA
| | - Emma E Furth
- b Department of Pathology , University of Pennsylvania , Philadelphia , PA , USA
| | - Kaitlin Kennard
- a Lymphoma Program, Abramson Cancer Center , University of Pennsylvania , Philadelphia , PA , USA
| | - Sunita Dwivedy Nasta
- a Lymphoma Program, Abramson Cancer Center , University of Pennsylvania , Philadelphia , PA , USA
| | - Jakub Svoboda
- a Lymphoma Program, Abramson Cancer Center , University of Pennsylvania , Philadelphia , PA , USA
| | - David L Porter
- a Lymphoma Program, Abramson Cancer Center , University of Pennsylvania , Philadelphia , PA , USA
| | - Anthony R Mato
- c CLL Program, Leukemia Service , Memorial Sloan- Kettering Cancer Center , New York , NY , USA
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15
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Suda K, Muraji T, Ohtani H, Aiyoshi T, Sasaki T, Toma M, Yanai T. Histological significance of hepatitis-like findings in biliary atresia: An analysis of 34 Japanese cases. Pediatr Int 2019; 61:364-368. [PMID: 30811786 DOI: 10.1111/ped.13816] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 12/21/2018] [Accepted: 02/23/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hepatocellular injury including multinuclear changes are common histological features in biliary atresia (BA), as well as in neonatal hepatitis. To date, however, no reports have examined how those findings correlate with the prognosis of BA. We clarified the clinical implications of hepatitis-related changes in BA on histological analysis. METHODS We retrospectively reviewed 34 cases of BA treated over the past 30 years at Ibaraki Children's Hospital. Liver biopsy specimens during Kasai procedures were evaluated for hepatocyte multinuclear change, ballooning, and acidophilic body, hereby defined as hepatitis-like findings (HLF). Each finding was semi-quantitatively scored as 0-2, and their sum was defined as the HLF score, ranging from 0 to 6. We examined the correlation between HLF score and total bilirubin (T-Bil), direct bilirubin (D-Bil), and other liver function test results at the Kasai procedure, as well as 1 week, and 1, 3, and 6 months after the Kasai procedure. Subsequently, HLF score was compared between native liver survivors (NLS; n = 16) and non-NLS (n = 18) for long-term analyses. RESULTS Hepatitis-like findings score except for aspartate aminotransferase (AST), had no correlation with the preoperative data. HLF score was positively correlated, however, with T-Bil, D-Bil, and AST at 1 week and 1 month after the Kasai procedure (1 week: P = 0.009, 0.023, and 0.019; 1 month: 0.022, 0.019, and 0.013, respectively). HLF score was not significantly different between the NLS and non-NLS groups. CONCLUSION Higher HLF score at Kasai procedure is an indicator of poor liver function at short-term follow up.
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Affiliation(s)
- Kazuto Suda
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Mito, Ibaraki, Japan
| | - Toshihiro Muraji
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Mito, Ibaraki, Japan.,Department of Pediatric Surgery, Kirishima Medical Center affiliated with Research Field in Medical and Health Sciences, Kagoshima University, Kirishima, Kagoshima, Japan
| | - Haruo Ohtani
- Department of Pathology, Ibaraki Children's Hospital, Mito, Ibaraki, Japan
| | - Tsubasa Aiyoshi
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Mito, Ibaraki, Japan
| | - Takato Sasaki
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Mito, Ibaraki, Japan
| | - Miki Toma
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Mito, Ibaraki, Japan
| | - Toshihiro Yanai
- Department of Pediatric Surgery, Ibaraki Children's Hospital, Mito, Ibaraki, Japan
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16
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Abstract
Cholestasis refers to impairment in formation or excretion of bile. This can be due to defects in intrahepatic production of bile, defects in the transmembrane transport of bile, or mechanical obstruction to bile flow. Clinical features of cholestasis reflect the retention of components of bile (bilirubin, bile acids, cholesterol) in the body. In the neonatal period, hyperbilirubinemia can be categorized as either unconjugated (and often benign) hyperbilirubinemia, or conjugated hyperbilirubinemia due to cholestasis. It is for this reason that the first laboratory evaluation in a patient with jaundice, dark urine, and/or acholic stool is a fractionated bilirubin. This article serves as a practical primer for pediatric and neonatology trainees and covers common causes of neonatal cholestasis, as well as the diagnostic work-up and treatment. Causes that are discussed include biliary atresia, idiopathic neonatal hepatitis, gestational alloimmune liver disease, metabolic and genetic diseases, total parenteral nutrition cholestasis, and congenital infection. [Pediatr Ann. 2018;47(11):e433-e439.].
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17
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Postinfantile Giant Cell Hepatitis with Features of Acute Severe Autoimmune Hepatitis Probably Triggered by Diclofenac in a Patient with Primary Myelofibrosis. Case Reports Hepatol 2018; 2018:9793868. [PMID: 29713554 PMCID: PMC5866856 DOI: 10.1155/2018/9793868] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 01/11/2018] [Accepted: 02/11/2018] [Indexed: 01/28/2023] Open
Abstract
Giant cell hepatitis (GCH) is commonly reported in neonatal and infantile liver diseases but rarely in adults where the term postinfantile GCH (PIGCH) is used. PIGCH is associated with many diseases, including drugs toxicity, viruses, and autoimmune liver diseases, with autoimmune hepatitis (AIH) being the most prevalent. We present a case of PIGCH in a 76-year-old female without known history of liver disease who suffered from an acute severe episode of hepatitis. After careful exclusion of other hepatitis causes by imaging, virological, immunological, and microbiological investigations, a diagnosis of acute severe AIH (AS-AIH) was established. The patient was started on corticosteroids but she did not respond and died 3 days later because of advanced acute liver failure. Postmortem liver biopsy showed typical PIGCH lesions. Physicians must keep this catastrophic entity in mind in cases of unexplained acute liver injury as, contrary to our case, prompt rescue therapy with corticosteroids may be life-saving.
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18
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Zhou T, Zhang JJ, Luo Y, Liu Y, Zhuang SY, Xue F, Han LZ, Xia Q. Clinical characteristics and outcome of liver transplantation for Alagille syndrome in children. J Dig Dis 2017. [PMID: 28644566 DOI: 10.1111/1751-2980.12500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Tao Zhou
- Department of Liver Surgery and Liver Transplantation Center, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jian Jun Zhang
- Department of Liver Surgery and Liver Transplantation Center, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yi Luo
- Department of Liver Surgery and Liver Transplantation Center, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuan Liu
- Department of Liver Surgery and Liver Transplantation Center, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shao Yong Zhuang
- Department of Liver Surgery and Liver Transplantation Center, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Feng Xue
- Department of Liver Surgery and Liver Transplantation Center, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Long Zhi Han
- Department of Liver Surgery and Liver Transplantation Center, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qiang Xia
- Department of Liver Surgery and Liver Transplantation Center, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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19
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Wada K, Kobayashi H, Moriyama A, Haneda Y, Mushimoto Y, Hasegawa Y, Onigata K, Kumori K, Ishikawa N, Maruyama R, Sogo T, Murphy L, Taketani T. A case of an infant with congenital combined pituitary hormone deficiency and normalized liver histology of infantile cholestasis after hormone replacement therapy. Clin Pediatr Endocrinol 2017; 26:251-257. [PMID: 29026274 PMCID: PMC5627226 DOI: 10.1297/cpe.26.251] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/19/2017] [Indexed: 12/14/2022] Open
Abstract
Congenital combined pituitary hormone deficiency (CPHD) may present with cholestasis in
the neonate or during early infancy. However, its precise mechanism is unknown. A 3-mo-old
boy presented with cryptorchidism and hypoplastic scrotum after birth. Neonatal jaundice
was noted but temporarily improved with phototherapy. Jaundice recurred at 2 mo of age.
Elevated direct bilirubin (D-Bil) and liver dysfunction were found but cholangiography
showed no signs of biliary atresia (BA). Liver biopsy findings showed giant cell formation
of hepatocytes with hypoplastic bile ducts. Subsequent magnetic resonance imaging (MRI) of
the head revealed a hypoplastic pituitary gland with an ectopic posterior lobe, and the
patient was diagnosed with congenital CPHD based on decreased secretion of cortisol and GH
by the pituitary anterior lobe load test. D-Bil levels promptly improved after
hydrocortisone (HDC) replacement. We subsequently began replacement with levothyroxine
(L-T4) and GH, and liver histology showed normal interlobular bile ducts at 8
mo old. This is the first case report of proven histological improvement after hormone
replacement therapy. This suggested that pituitary-mediated hormones, especially cortisol,
might be involved in the development of the bile ducts.
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Affiliation(s)
- Keisuke Wada
- Department of Pediatrics, School of Medicine, Shimane University, Shimane, Japan
| | - Hironori Kobayashi
- Department of Pediatrics, School of Medicine, Shimane University, Shimane, Japan
| | - Aisa Moriyama
- Department of Pediatrics, School of Medicine, Shimane University, Shimane, Japan
| | - Yasuhiro Haneda
- Department of Pediatrics, School of Medicine, Shimane University, Shimane, Japan
| | - Yuichi Mushimoto
- Department of Pediatrics, School of Medicine, Shimane University, Shimane, Japan
| | - Yuki Hasegawa
- Department of Pediatrics, School of Medicine, Shimane University, Shimane, Japan
| | - Kazumichi Onigata
- Department of Pediatrics, School of Medicine, Shimane University, Shimane, Japan
| | - Koji Kumori
- Department of Digestive and General Surgery, School of Medicine, Shimane University, Shimane, Japan
| | | | - Riruke Maruyama
- Department of Pathology, Shimane University Hospital, Shimane, Japan
| | - Tsuyoshi Sogo
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohama City Tobu Hospital, Kanagawa, Japan
| | - Lynne Murphy
- Department of Medical English Education, School of Medicine, Shimane University, Shimane, Japan
| | - Takeshi Taketani
- Department of Pediatrics, School of Medicine, Shimane University, Shimane, Japan
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20
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21
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Ryabets-Lienhard A, Stewart C, Borchert M, Geffner ME. The Optic Nerve Hypoplasia Spectrum: Review of the Literature and Clinical Guidelines. Adv Pediatr 2016; 63:127-46. [PMID: 27426898 DOI: 10.1016/j.yapd.2016.04.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Anna Ryabets-Lienhard
- Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA.
| | - Carly Stewart
- The Vision Center, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA
| | - Mark Borchert
- The Vision Center, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA; The Saban Research Institute, Children's Hospital Los Angeles, 4661 Sunset Boulevard, Los Angeles, CA 90027, USA
| | - Mitchell E Geffner
- Center for Endocrinology, Diabetes, and Metabolism, Children's Hospital Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA 90027, USA; The Saban Research Institute, Children's Hospital Los Angeles, 4661 Sunset Boulevard, Los Angeles, CA 90027, USA
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22
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Götze T, Blessing H, Grillhösl C, Gerner P, Hoerning A. Neonatal Cholestasis - Differential Diagnoses, Current Diagnostic Procedures, and Treatment. Front Pediatr 2015; 3:43. [PMID: 26137452 PMCID: PMC4470262 DOI: 10.3389/fped.2015.00043] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 04/29/2015] [Indexed: 12/18/2022] Open
Abstract
Cholestatic jaundice in early infancy is a complex diagnostic problem. Misdiagnosis of cholestasis as physiologic jaundice delays the identification of severe liver diseases. In the majority of infants, prolonged physiologic jaundice represent benign cases of breast milk jaundice, but few among them are masked and caused by neonatal cholestasis (NC) that requires a prompt diagnosis and treatment. Therefore, a prolonged neonatal jaundice, longer than 2 weeks after birth, must always be investigated because an early diagnosis is essential for appropriate management. To rapidly identify the cases with cholestatic jaundice, the conjugated bilirubin needs to be determined in any infant presenting with prolonged jaundice at 14 days of age with or without depigmented stool. Once NC is confirmed, a systematic approach is the key to reliably achieve the diagnosis in order to promptly initiate the specific, and in many cases, life-saving therapy. This strategy is most important to promptly identify and treat infants with biliary atresia, the most common cause of NC, as this requires a hepatoportoenterostomy as soon as possible. Here, we provide a detailed work-up approach including initial treatment recommendations and a clinically oriented overview of possible differential diagnoses in order to facilitate the early recognition and a timely diagnosis of cholestasis. This approach warrants a broad spectrum of diagnostic procedures and investigations including new methods that are described in this review.
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Affiliation(s)
- Thomas Götze
- Department for Pediatric and Adolescent Medicine, Friedrich-Alexander University of Erlangen-Nuremberg , Erlangen , Germany
| | - Holger Blessing
- Department for Pediatric and Adolescent Medicine, Friedrich-Alexander University of Erlangen-Nuremberg , Erlangen , Germany
| | - Christian Grillhösl
- Department for Pediatric and Adolescent Medicine, Friedrich-Alexander University of Erlangen-Nuremberg , Erlangen , Germany
| | - Patrick Gerner
- Department for Pediatric and Adolescent Medicine, Albert-Ludwigs-University Freiburg , Freiburg , Germany
| | - André Hoerning
- Department for Pediatric and Adolescent Medicine, Friedrich-Alexander University of Erlangen-Nuremberg , Erlangen , Germany
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23
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Lee CN, Tiao MM, Chen HJ, Concejero A, Chen CL, Huang YH. Characteristics and outcome of liver transplantation in children with Alagille syndrome: a single-center experience. Pediatr Neonatol 2014; 55:135-8. [PMID: 24113225 DOI: 10.1016/j.pedneo.2013.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 06/24/2013] [Accepted: 09/02/2013] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND This study was carried out in Chang Gung Memorial Hospital-Kaohsiung Medical Center, Taiwan, with the aim of reviewing the characteristics and the outcome of liver transplantation (LT) in children with Alagille syndrome (AGS). METHODS We performed a retrospective analysis of transplant records of children diagnosed with AGS and undergoing LT between 1987 and 2010. RESULTS Nine patients underwent living donor LT. Cholestasis and characteristic facies were seen in all patients. Posterior embryotoxon was seen in 4/9 (44.4%), butterfly vertebrae in 3/9 (33.3%), heart defect (pulmonary stenosis in 2) in 3/9 (33.3%), and renal disease in 2/9 (22.2%) patients. Five cases had cholestasis prior to the age of 60 days, whereas four cases had cholestasis after 60 days of age. Iminodiacetic acid scans showed no excretion of isotope into the bowel in four cases and suggested a false diagnosis of biliary atresia. All patients underwent diagnostic laparotomy and liver biopsy. Results of liver biopsy showed characteristic features of paucity of interlobular bile ducts in all patients. Kasai portoenterostomy was not performed in any patient prior to being referred for LT. The mean age at the time of LT was 4.6 years. The 5-year overall survival rate after living donor LT was 88.9%. CONCLUSION Our conclusion is that the clinical features of AGS are informative. In addition, histological confirmation is important in the diagnosis. AGS children with severe liver disease had good prognoses with LT.
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Affiliation(s)
- Chi-Ning Lee
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Pediatrics, Zuoying Branch of Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - Mao-Meng Tiao
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Hung-Jen Chen
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Allan Concejero
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chao-Long Chen
- Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ying-Hsien Huang
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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24
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Morotti RA, Jain D. Pediatric Cholestatic Disorders: Approach to Pathologic Diagnosis. Surg Pathol Clin 2013; 6:205-225. [PMID: 26838972 DOI: 10.1016/j.path.2013.03.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
This article addresses select liver diseases that are commonly seen in the pediatric group and pose diagnostic challenges in practice. The key genetic/molecular abnormalities, clinical features, histopathologic findings, diagnostic modalities, differential diagnoses, and possible pitfalls in diagnosis are discussed in detail. Although recent advances in understanding the pathophysiology of bile synthesis and transport along with advances in molecular genetics have allowed a better characterization of many of these liver diseases, significant overlap in the histopathologic features of many of these disorders still leads to diagnostic challenges for the pathologist.
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Affiliation(s)
- Raffaella A Morotti
- Department of Pathology, Yale University School of Medicine, 310 Cedar Street, PO Box 208023, New Haven, CT 06520-8023, USA.
| | - Dhanpat Jain
- Department of Pathology, Yale University School of Medicine, 310 Cedar Street, PO Box 208023, New Haven, CT 06520-8023, USA
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25
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Mizooku H, Kagawa Y, Matsuda K, Okamoto M, Taniyama H. Histological and immunohistochemical evaluations of lobular dissecting hepatitis in American cocker spaniel dogs. J Vet Med Sci 2012; 75:597-603. [PMID: 23292109 DOI: 10.1292/jvms.12-0447] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Histological and immunohistochemical evaluations of lobular dissecting hepatitis (LDH) were performed in nine American cocker spaniel dogs. Histological examination showed diffuse fibrosis with weak inflammatory reaction of extensive neutrophils, macrophages, lymphocytes and plasma cells. Immunohistochemical examination revealed that the myofibroblastic cells positive for anti-α-smooth muscle actin and anti-vimentin antibodies produced reticular and collagen fibers and brought about the dissection of hepatic cords and diffuse disappearance of hepatocytes. Reticular fibers invading between hepatocytes and the surrounding small group of hepatocytes were strongly positive for anti-collagen type III and anti-collagen type IV antibodies. The positivity to anti-fibronectin and anti-laminin antibodies was frequently continuous on the basement membrane of the sinusoids of the remaining hepatic cords and between the hepatocytes. Positive findings for anti-E-cadherin antibody were not observed between the hepatocytes showing positive findings for anti-collagen type III and anti-collagen type IV antibodies. These results may explain the expression of fibronectin and laminin that occurs prior to the invasion of reticular fibers between hepatocytes. The present study further suggests that expression of an extracellular matrix mainly containing fibronectin and laminin between the hepatocytes and proliferation of collagen fibers and reticular fibers have a major role in the rupture of the hepatic cords and disappearance of hepatocytes.
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Affiliation(s)
- Hiroko Mizooku
- Department of Veterinary Pathology, School of Veterinary Medicine, Rakuno Gakuen University, 582-1 Bunkyodai-Midorimachi, Ebetsu, Hokkaido 069-8501, Japan
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26
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Moreira RK, Cabral R, Cowles RA, Lobritto SJ. Biliary atresia: a multidisciplinary approach to diagnosis and management. Arch Pathol Lab Med 2012; 136:746-60. [PMID: 22742548 DOI: 10.5858/arpa.2011-0623-ra] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Biliary atresia is an inflammatory cholangiopathy of infancy that results in progressive fibrosis and obliteration of bile ducts and represents the main indication for liver transplant in young children. In spite of extensive investigation, its etiology has remained poorly understood. Timely surgical intervention (Kasai procedure) may result in significant benefit to these patients and represents the final goal of an accurate diagnostic evaluation. OBJECTIVE To present an overview of biliary atresia, including clinical and surgical approaches to this disease, with emphasis on the histopathologic evaluation. DATA SOURCES Review of relevant literature indexed in PubMed (US National Library of Medicine). CONCLUSION A well-coordinated multidisciplinary approach is required in the assessment of suspected cases of biliary atresia. Pathologic examination of biopsy specimens is an integral part of the diagnostic algorithm and, therefore, plays a pivotal role in the diagnostic evaluation of this disease.
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Affiliation(s)
- Roger Klein Moreira
- Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA.
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Liu Y, Huang ZH, Xu SQ, Huang YJ, Zhou H, Dong YS, Feng JX. Value of histopathologic examination in differential diagnosis of infantile cholestasis. Shijie Huaren Xiaohua Zazhi 2012; 20:2200-2204. [DOI: 10.11569/wcjd.v20.i23.2200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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
AIM: To compare differences in liver histopathology between extrahepatic biliary atresia (EHBA) and infantile cholestatic infantile hepatitis (IH) and to explore the value of liver histopathologic examination in differential diagnosis of these diseases.
METHODS: The clinical data for 65 patients with EHBA and 24 patients with IH who were pathologically diagnosed from April 2002 to December 2009 were retrospectively analyzed.
RESULTS: There were some common histopathologic features between EHBA and IH. The major histopathological features of EHBA were bile duct proliferation, portal fibrosis and inflammatory cell infiltration (all P < 0.05), while the outstanding features of IH were hepatic giant cell transformation and extramedullary hematopoiesis (both P < 0.05).
CONCLUSION: Although there are some differences between EHBA and IH in histopathologic features, some features are overlapped. Therefore, clinical features for the patients should also be considered. In some cases, exploratory laparotomy is required for differential diagnosis.
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