Autoimmune hepatitis (AIH) with acute presentation is classified in acute exacerbation of chronic hepatitis AIH and acute-onset AIH (acute hepatitis phase) without preceding chronic liver disease. The latter, especially, often lacks the clinicopathological features of AIH and its diagnostic criteria has not been established. As a characteristic histology of AIH with acute presentation, centrilobular necrosis (CN) is well-known. However, CN is a feature of drug-induced liver injury (DILI) and histologically distinguishing acute-onset AIH from DILI remains a challenge. In this review, the basic histological findings of AIH showing chronic and acute presentation and the helpful points in the differential diagnosis are described.
We investigated retrospectively about microorganism, background, clinical course of 153 liver abscesses (LA) over two decades. In pyogenic liver abscess (PLA), diabetes, malignancy, and biliary tract disease were significantly higher than those of amoebic liver abscess (ALA). The pathogenic microorganism of PLA are major in the order of Klebsiella pneumoniae, Escherichia coli. The detection rate of blood culture was 44%, whereas that of abscess culture was as high as 83%. The frequency of pathogenic microorganism that are resistant to antibiotic drugs was low. Patients with ALA is characterized by heavy drinkers. And, it's worth noting that there is an onset during immunosuppressive therapy in asymptomatic cysts whose infection route is unknown. Since LA has severe cases, it is important to perform abscess culture early and treat it properly. Especially, we should care cases with malignancy, with multiple bacteria coinfection, and with abscess formation in multiple organs.
A 64-year-old man with complaints of general fatigue and high fever was admitted because of liver dysfunction. He had a history of eating raw oysters 2 weeks before. His laboratory data on hospital day 1 were as follows: total bilirubin (TB), 1.16 mg/dl; aspartate aminotransferase (AST), 1870 IU/L; alanine aminotransferase (ALT), 1042 IU/L and PT activity, 77.6%. On the second day, his liver injury worsened rapidly on the basis of the following values: TB, 3.02 mg/dl; AST, 5400 IU/L; ALT, 2945 IU/L and PT activity, 47.5%. The risk of hepatic encephalopathy development in acute liver injury on the second day was calculated 13.5%; therefore, high-dose corticosteroid therapy was administered. The liver injury improved. Later, the etiology of liver injury was found to be hepatitis A infection. Genotype IIIA is often found in South Asia and is different from the genotype IIIA clusters found in the outbreak in Korea.
A 66-year-old man was admitted for the examination of the huge liver mass in the right lobe by abdominal ultrasonography. Five years earlier, he received an operation for meningeal hemangiopericytoma (HPC) at the department of neurosurgery in our hospital. In imaging studies, an approximately 15 cm mass of the right lobe and multiple metastases in the whole liver, multiple lung metastases, and multiple bone metastases including vertebral bodies were observed. The liver mass was pathologically diagnosed to be a metastatic HPC by an ultrasound-guided needle biopsy. Immunohistochemically, the tumor was positive for STAT6, high levels of Ki-67 positive, but are negative for synaptophysin, chromogranin A, hepatocyte, desmin, c-kit, S100, and CD34. He was re-hospitalized of hypoglycemic episodes 45 days after the first admission. After administering oral prednisolone, hypoglycemic episodes improved, and he died of tumor progression 124 days after admission.
A 73-year-old man contracted acute hepatitis E with decreased platelet count in the course of chemotherapy against advanced gastric cancer and administration of corticosteroid for adverse effects of chemotherapy. After the recovery of hepatitis, he underwent the first administration of Nivolumab, and subsequently died of bleeding from the cancer by immune-mediated severe thrombocytopenia. The relationship between the thrombocytopenia after Nivolumab therapy and prior hepatitis E virus (HEV) infection cannot be excluded. The patient ate pig offal before hepatitis E, and the HEV strain obtained from the patient was of genotype 3b, which was prevalent in Japanese pigs. HEV infection should be considered as the cause of liver dysfunction and thrombocytopenia during chemotherapy or treatment by immuno-suppressive agents.