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Bitar R, Kaur M, Crandall I, McNamara R, Revzin MV. Ultrasound evaluation of portal venous gas and its mimics. Abdom Radiol (NY) 2024; 49:2756-2769. [PMID: 38735019 DOI: 10.1007/s00261-024-04328-2] [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: 01/31/2024] [Revised: 03/31/2024] [Accepted: 04/02/2024] [Indexed: 05/13/2024]
Abstract
Portal venous gas on abdominal ultrasound classically represents an indirect indicator of bowel ischemia, a critical condition which poses a high patient mortality and therefore warrants emergent corrective action. While the classic appearance of portal venous gas on ultrasound is well-described in the literature, the characteristic descriptors are nonspecific and may actually represent other less emergent mimics. Therefore, while radiologists should remain vigilant for the detection of findings corresponding to portal venous gas, they should also be aware of similar-appearing entities in order to provide the most accurate diagnosis. This pictorial essay will open with imaging examples of true portal venous gas attributable to bowel ischemia and describe the classic features which should alert radiologists to this specific diagnosis. Subsequently, this pictorial essay will provide imaging examples of other various other clinical entities which on ultrasound may share similar imaging characteristics. An important objective of this pictorial essay is to highlight distinguishing imaging features along with specific clinical circumstances for each pathological entity which can direct radiologists into identifying the correct diagnosis.
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Affiliation(s)
- Ryan Bitar
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Manroop Kaur
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Ian Crandall
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Robert McNamara
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Margarita V Revzin
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA.
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2
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Harper LJ, Farver CF, Yadav R, Culver DA. A framework for exclusion of alternative diagnoses in sarcoidosis. J Autoimmun 2024:103288. [PMID: 39084998 DOI: 10.1016/j.jaut.2024.103288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 07/02/2024] [Accepted: 07/13/2024] [Indexed: 08/02/2024]
Abstract
Sarcoidosis is a multisystem granulomatous syndrome that arises from a persistent immune response to a triggering antigen(s). There is no "gold standard" test or algorithm for the diagnosis of sarcoidosis, making the diagnosis one of exclusion. The presentation of the disease varies substantially between individuals, in both the number of organs involved, and the manifestations seen in individual organs. These qualities dictate that health care providers diagnosing sarcoidosis must consider a wide range of possible alternative diagnoses, from across a range of presentations and medical specialties (infectious, inflammatory, cardiac, neurologic). Current guideline-based diagnosis of sarcoidosis recommends fulfillment of three criteria: 1) compatible clinical presentation and/or imaging 2) demonstration of granulomatous inflammation by biopsy (when possible) and, 3) exclusion of alternative causes, but do not provide guidance on standardized strategies for exclusion of alternative diagnoses. In this review, we provide a summary of the most common differential diagnoses for sarcoidosis involvement of lung, eye, skin, central nervous system, heart, liver, and kidney. We then propose a framework for testing to exclude alternative diagnoses based on pretest probability of sarcoidosis, defined as high (typical findings with sarcoidosis involvement confirmed in another organ), moderate (typical findings in a single organ), or low (atypical/findings suggesting of an alternative diagnosis). This work highlights the need for informed and careful exclusion of alternative diagnoses in sarcoidosis.
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Affiliation(s)
- Logan J Harper
- Department of Pulmonary and Critical Care Medicine, Integrated Hospital Care Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Carol F Farver
- Department of Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - Ruchi Yadav
- Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel A Culver
- Department of Pulmonary and Critical Care Medicine, Integrated Hospital Care Institute, Cleveland Clinic, Cleveland, OH, USA
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Suzuki T, Hayakawa Y, Kaneko S, Takenaka K, Watakabe K, Kinowaki Y, Takemoto A, Ohtsuka K, Asahina Y, Okamoto R. Granulomatous hepatitis with Crohn's disease: a case report. Clin J Gastroenterol 2024; 17:551-556. [PMID: 38502473 DOI: 10.1007/s12328-024-01937-8] [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: 09/26/2023] [Accepted: 02/07/2024] [Indexed: 03/21/2024]
Abstract
A 45-year-old man who was regularly followed up for Crohn's disease (CD) and maintained clinical remission with vedolizumab (VDZ). At 37 years old, he was diagnosed CD from longitudinal ulcers in the distal ileum by balloon-assisted enteroscopy (BAE). During the follow-up, liver enzyme elevation, splenomegaly and thrombocytopenia were in progress. Esophagogastric varices suggested chronic liver disease and portal hypertension. Magnetic resonance elastography (MRE) showed liver stiffness of 3.4 kPa and proton density fat fraction (PDFF) of 1.86%. He was diagnosed with granulomatous hepatitis based on a liver biopsy. The hepatic venous pressure gradient (HVPG) was mildly elevated at 7 mmHg, consistent with the pre-sinusoidal portal hypertension due to granulomatous hepatitis. We report a rare case with granulomatous hepatitis diagnosed from liver injury and portal hypertension, despite the stable intestinal symptoms of CD.
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Affiliation(s)
- Tatsuya Suzuki
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Yuka Hayakawa
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Shun Kaneko
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan.
| | - Kento Takenaka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Keiya Watakabe
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Yuko Kinowaki
- Department of Comprehensive Pathology, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akira Takemoto
- Bioresource Research Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuo Ohtsuka
- Endoscopic Unit, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Yasuhiro Asahina
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
- Department of Liver Disease Control, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryuichi Okamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
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4
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Iordache A, Fuursted K, Rift CV, Rasmussen A, Willemoe GL, Hasselby JP. Hepatic granulomas following liver transplantation: A retrospective survey, and analysis of possible microbiological etiology. Pathol Res Pract 2024; 255:155201. [PMID: 38367601 DOI: 10.1016/j.prp.2024.155201] [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: 11/10/2023] [Revised: 01/31/2024] [Accepted: 02/05/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Liver granulomas have always been a diagnostic challenge for pathologists. They have been described in up to 15% of liver biopsies and can also be seen in liver allograft biopsy specimens, but there is a paucity of information regarding the prevalence and associated etiologic factors of granulomas in liver transplanted patients. The aim of this study is to shed light on the etiology of liver granulomas. METHODS Liver biopsies from liver transplanted patients, in the period from 01.01.2011 - 01.05.2017, were examined. We registered the histo-morphological characteristics and clinicopathological data of all biopsies and performed next-generation sequencing (NGS) to detect possible pathogens (bacteria, fungi, and parasites) in the biopsies containing granulomas. RESULTS We reviewed a total of 400 liver biopsies from 217 liver transplant patients. Of these, 131 liver biopsies (32.8%) from 98 patients (45.2%) revealed granulomas. Most were epithelioid granulomas located parenchymal and were detected in 115 (87.7%) biopsies. We also identified 10 cases (7.6%) with both lobular and portal granulomas and six biopsies (4.5%) with portal granulomas alone. In 54 biopsies (41.2%), granulomas were found in biopsies with acute cellular rejection (ACR). Fifty (51%) patients with granulomas underwent liver transplantation for autoimmune-related end-stage liver disease (AILD). The granulomas were found most frequently in the first six months after transplantation, where patients also more often were biopsied. NGS analysis did not reveal any potential infectious agent, and no significant differences were observed in the microbiological diversity (microbiome) between clinical- and granuloma characteristics concerning bacteria, fungi, and parasites. CONCLUSION Our study confirmed that granulomas are frequently seen in liver allograft biopsy specimens, and most often localized in the parenchyma, occurring in the first post-transplant period in patients with AILD, and often seen simultaneously with episodes of ACR. Neither a specific microbiological etiological agent nor a consistent microbiome was detected in any case.
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Affiliation(s)
- Anisoara Iordache
- Department of Pathology, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark
| | - Kurt Fuursted
- Department of Microbiology and Infection Control, Reference Laboratory, Statens Serum Institut, Artillerivej 5, DK-2300 Copenhagen S, Denmark
| | | | - Allan Rasmussen
- Department of Surgical Gastroenterology, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark
| | - Gro Linno Willemoe
- Department of Pathology, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark
| | - Jane Preuss Hasselby
- Department of Pathology, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen Ø, Denmark
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5
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Shah N, Dib EG, Joseph N, Fontana RJ. Granulomatous hepatitis: Is it bugs, drugs, or other untoward culprits? Clin Liver Dis (Hoboken) 2024; 23:e0125. [PMID: 38623150 PMCID: PMC11018189 DOI: 10.1097/cld.0000000000000125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 12/03/2023] [Indexed: 04/17/2024] Open
Affiliation(s)
- Neil Shah
- Department of Internal Medicine, Trinity Health, Ann Arbor, Michigan, USA
| | - Elie G. Dib
- Department of Internal Medicine, Trinity Health, Ann Arbor, Michigan, USA
| | - Nora Joseph
- Department of Pathology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Robert J. Fontana
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
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Delamarre A, Boillet G, de Lédinghen V. [What to do when faced with a chronic elevation of transaminases]. Rev Med Interne 2023; 44:555-560. [PMID: 37597973 DOI: 10.1016/j.revmed.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/12/2023] [Accepted: 07/29/2023] [Indexed: 08/21/2023]
Abstract
Chronic elevation of transaminases is recurring issue in primary care. This article aims to be practical. It offers a quick reminder of epidemiology, pathophysiology, concept of normal values of transaminases, main causes (alcohol, fatty liver disease, viral hepatitis) and first-line assessment. Then, we will go further in less frequent causes, extra-hepatic causes and additional tests. We will precise what is the role of general practitioner in this care pathway and when to address patient to specialist.
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Affiliation(s)
- A Delamarre
- Service d'hépatologie et de transplantation hépatique, hôpital Haut-Lévêque, centre hospitalier universitaire de Bordeaux, Bordeaux, France; BRIC, Inserm U1312, université de Bordeaux, Bordeaux, France
| | - G Boillet
- Service d'hépatologie et de transplantation hépatique, hôpital Haut-Lévêque, centre hospitalier universitaire de Bordeaux, Bordeaux, France
| | - V de Lédinghen
- Service d'hépatologie et de transplantation hépatique, hôpital Haut-Lévêque, centre hospitalier universitaire de Bordeaux, Bordeaux, France; BRIC, Inserm U1312, université de Bordeaux, Bordeaux, France.
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7
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Samynathan A, Saardi K, Akiska YM, Sadur A, Johnson S, Nasseri M. "Skin Popping" and "Shooter's Patch" As Manifestations of Intradermal Drug Abuse. Cureus 2023; 15:e45251. [PMID: 37842500 PMCID: PMC10576613 DOI: 10.7759/cureus.45251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 10/17/2023] Open
Abstract
Talc, a common adulterant in injectable opioids and filler in oral tablets, is frequently abused as crushed suspensions in injections. This review aims to recognize intradermal drug injection referred to colloquially as "skin popping" or "shooter's patch" as a cause of granulomatous disease and prevention of systemic complications from cutaneous cues.
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Affiliation(s)
- Archana Samynathan
- Department of Dermatology, George Washington University School of Medicine and Health Sciences, Washington, D.C., USA
- Department of Dermatology, Bangalore Medical College and Research Institute, Bangalore, IND
| | - Kaarl Saardi
- Department of Dermatology, George Washington University School of Medicine and Health Sciences, Washington, D.C., USA
| | - Yagiz M Akiska
- Department of Dermatology, George Washington University School of Medicine and Health Sciences, Washington, D.C., USA
| | - Alana Sadur
- Department of Dermatology, George Washington University School of Medicine and Health Sciences, Washington, D.C., USA
| | - Skylar Johnson
- Department of Dermatology, George Washington University School of Medicine and Health Sciences, Washington, D.C., USA
| | - Mana Nasseri
- Department of Dermatology, George Washington University School of Medicine and Health Sciences, Washington, D.C., USA
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Fontana RJ, Kleiner DE, Chalasani N, Bonkovsky H, Gu J, Barnhart H, Li YJ, Hoofnagle JH. The Impact of Patient Age and Corticosteroids in Patients With Sulfonamide Hepatotoxicity. Am J Gastroenterol 2023; 118:1566-1575. [PMID: 36848311 PMCID: PMC10511659 DOI: 10.14309/ajg.0000000000002232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/10/2023] [Indexed: 03/01/2023]
Abstract
INTRODUCTION Sulfonamides are widely used to treat and prevent various bacterial and opportunistic infections. The aim of this study was to describe the clinical presentation and outcomes of a large cohort of patients with sulfonamide hepatotoxicity. METHODS Between 2004 and 2020, 105 patients with hepatotoxicity attributed to trimethoprim/sulfamethoxazole (TMP-SMZ) (n = 93) or other sulfonamides (n = 12) were enrolled. Available liver biopsies were reviewed by a single hepatopathologist. RESULTS Among the 93 TMP-SMZ cases, 52% were female, 7.5% younger than 20 years, and the median time to drug-induced liver injury (DILI) onset was 22 days (range: 3-157). Younger patients were significantly more likely to have rash, fever, eosinophilia, and a hepatocellular injury pattern at onset that persisted at the peak of liver injury compared with older patients ( P < 0.05). The 18 (19%) TMP-SMZ patients treated with corticosteroids had more severe liver injury and a higher mortality but a trend toward more rapid normalization of their laboratory abnormalities compared with untreated patients. During follow-up, 6.2% of the TMP-SMZ patients died or underwent liver transplantation. Chronic DILI developed in 20% and was associated with cholestatic injury at onset and higher peak total bilirubin levels. DISCUSSION Sulfonamide hepatotoxicity is characterized by a short drug latency with frequent hypersensitivity features at onset. Subject age is an important determinant of the laboratory profile at presentation, and patients with cholestasis and higher total bilirubin levels were at increased risk of developing chronic DILI. Corticosteroids may benefit a subgroup of patients with severe injury, but further studies are needed.
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Affiliation(s)
- Robert J. Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - David E. Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN
| | - Herbert Bonkovsky
- Section on Gastroenterology & Hepatology, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Jiezhun Gu
- Duke Clinical Research Institute, Durham, NC
| | | | - Yi-Ju Li
- Duke Clinical Research Institute, Durham, NC
| | - Jay H. Hoofnagle
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
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9
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Bai X, Levental M, Karaplis AC. Burosumab Treatment for Autosomal Recessive Hypophosphatemic Rickets Type 1 (ARHR1). J Clin Endocrinol Metab 2022; 107:2777-2783. [PMID: 35896139 PMCID: PMC9516063 DOI: 10.1210/clinem/dgac433] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Autosomal recessive hypophosphatemic rickets (ARHR) are rare, heritable renal phosphate-wasting disorders that arise from overexpression of the bone-derived phosphaturic hormone fibroblast growth factor 23 (FGF23) leading to impaired bone mineralization (rickets and osteomalacia). Inactivating mutations of Dentin matrix protein 1 (DMP1) give rise to ARHR type 1 (ARHR1). Short stature, prominent bowing of the legs, fractures/pseudofractures, and severe enthesopathy are prominent in this patient population. Traditionally, treatment consists of oral phosphate replacement and the addition of calcitriol but this approach is limited by modest efficacy and potential renal and gastrointestinal side effects. OBJECTIVE The advent of burosumab (Crysvita), a fully humanized monoclonal antibody to FGF23 for the treatment of X-linked hypophosphatemia and tumor-induced osteomalacia, offers a unique opportunity to evaluate its safety and efficacy in patients with ARHR1. RESULTS Monthly administration of burosumab to 2 brothers afflicted with the disorder resulted in normalization of serum phosphate, healing of pseudofracture, diminished fatigue, less bone pain, and reduced incapacity arising from the extensive enthesopathy and soft tissue fibrosis/calcification that characterizes this disorder. No adverse effects were reported following burosumab administration. CONCLUSION The present report highlights the beneficial biochemical and clinical outcomes associated with the use of burosumab in patients with ARHR1.
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Affiliation(s)
- Xiuying Bai
- Lady Davis Institute for Medical Research, CIUSSS de Centre-Ouest-de-l’île-de-Montréal, Jewish General Hospital, McGill University, Montréal, Quebec, H3T 1E2, Canada
| | - Mark Levental
- Department of Radiology, CIUSSS de Centre-Ouest-de-l’île-de-Montréal, Jewish General Hospital, McGill University, Montréal, Quebec, H3T 1E2, Canada
| | - Andrew C Karaplis
- Correspondence: Andrew C. Karaplis, MD, PhD, Lady Davis Institute for Medical Research, 3755 Cote Steve Catherine, Montreal, QC, H3T 1E2, Canada.
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Saad E, Agab M, Ozcekirdek EC, Awadelkarim A, Idris I. The Diagnostic Dilemma of Acute Granulomatous Hepatitis in a Patient With Crohn's Disease: A Case Report and Review of Literature. J Investig Med High Impact Case Rep 2022; 10:23247096211069764. [PMID: 35343257 PMCID: PMC8966121 DOI: 10.1177/23247096211069764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Liver involvement is not an uncommon extraintestinal manifestation of inflammatory bowel disease (IBD). IBD-associated liver diseases may have a variety of etiopathogenetic origins (including shared autoimmune pathogenesis, the effect of chronic inflammatory status, and adverse effects of drugs). Nevertheless, acute granulomatous hepatitis in the setting of Crohn’s disease (CD) is a rare clinical entity. It warrants, however, a careful assessment as both clinical and pathological features of Crohn’s-associated granulomatous hepatitis closely mimic extrapulmonary hepatic sarcoidosis, with considerable overlaps between the 2 diseases, which certainly makes a definitive diagnosis quite challenging. It is crucial to exclude infectious etiologies during the evaluation of acute granulomatous hepatitis, as inappropriate immunosuppressive treatment may cause a systemic flare-up of an underlying liver infection. We report a rare case of a 35-year-old female with a history of CD who presented with recurrent fevers, acute abdominal pain, and cholestasis. She was found to have acute hepatitis with noncaseating granulomas on liver biopsy. A comprehensive diagnostic workup did not ultimately prove a specific etiological culprit. The patient was treated with oral corticosteroids, and she demonstrated a positive clinical and laboratory response to the treatment. Our case highlights the diagnostic dilemma of acute granulomatous hepatitis in the setting of co-existent CD with a multisystemic syndrome. Granulomatous hepatitis represents a relatively rare manifestation of both extraintestinal CD and extrapulmonary sarcoidosis, with potential difficulties discriminating between the 2 entities on many occasions. The case also demonstrates the value of an interdisciplinary approach in the context of multisystemic disease to achieve the best outcome.
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Affiliation(s)
- Eltaib Saad
- Saint Francis Presence Hospital, Evanston, IL, USA
| | - Mohamed Agab
- Saint Francis Presence Hospital, Evanston, IL, USA
| | | | | | - Isra Idris
- Woodhull Medical Center, Brooklyn, NY, USA
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11
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Choudhury A, Shukla J, Mahajan G, Jha DK, Gupta P, Sharma V. Hepatic tuberculosis: myriad of hues. Germs 2021; 11:310-313. [PMID: 34422701 DOI: 10.18683/germs.2021.1266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/03/2021] [Accepted: 05/06/2021] [Indexed: 11/08/2022]
Abstract
Introduction Gastrointestinal tuberculosis is an important form of extrapulmonary tuberculosis but liver involvement is uncommon. Hepatic tuberculosis can manifest in variable manners including as a space occupying lesion, diffuse infiltration by granulomas (granulomatous hepatitis) and as liver abscess. Hepatic tuberculosis is usually associated with lesions elsewhere but the diagnosis is often not considered because of rarity. Case report We report two cases of hepatic involvement by tuberculosis: one in the form of liver abscess and the other having multiple hypodense hepatic lesions along with peritoneal involvement. The presence of ascites, visceral scalloping and multiple hypodense lesions resulted in a diagnostic confusion with disseminated malignancy but GeneXpert Ultra (Cepheid, USA) helped in making the diagnosis. Discussion Hepatic tuberculosis should be considered in the differential diagnosis of hepatic space occupying lesions and abscesses. This is especially important in TB endemic regions and in patients where there is involvement of other organs especially the lungs. Conclusions Newer microbiological modalities including GeneXpert Ultra could help in making a diagnosis of hepatic tuberculosis.
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Affiliation(s)
- Arup Choudhury
- MD, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Jayendra Shukla
- MD, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Gaurav Mahajan
- MD, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Day Krishna Jha
- MD, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Pankaj Gupta
- MD, Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Vishal Sharma
- DM, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India
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12
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Conover KR, Cox CB, Wang H, Bhatt R, Hafberg ET. Pediatric Metastatic Crohn's Disease of the Liver. JPGN REPORTS 2021; 2:e107. [PMID: 37205958 PMCID: PMC10191507 DOI: 10.1097/pg9.0000000000000107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/15/2021] [Indexed: 05/21/2023]
Abstract
Metastatic Crohn's disease (MCD) is the manifestation of Crohn's disease outside of the gastrointestinal tract and most frequently involves mucocutaneous and pulmonary tissues. This is an uncommon phenomenon but is well characterized in the pediatric literature. In contrast, MCD affecting the liver has not previously been described in pediatrics. The pediatric gastroenterologist must be aware of the myriad of Crohn's disease-associated hepatopathies. We herein present the first reported case of pediatric MCD involving the liver and describe our targeted diagnostic evaluation and the patient's response to infliximab-dyyb.
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Affiliation(s)
- Katie R. Conover
- From the Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt
| | - Conrad B. Cox
- From the Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr. Children’s Hospital at Vanderbilt
| | - Huiying Wang
- Division of Pediatric Pathology, Department of Pathology, Microbiology, and Immunology, Monroe Carell Jr. Children’s Hospital at Vanderbilt
| | - Riha Bhatt
- From the Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr. Children’s Hospital at Vanderbilt
| | - Einar T. Hafberg
- From the Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Monroe Carell Jr. Children’s Hospital at Vanderbilt
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13
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Granuloma With an Underlying Lymphoma: A Diagnostic Challenge and a Wider Histologic Spectrum Including Adult T-Cell Leukemia/Lymphoma. Appl Immunohistochem Mol Morphol 2021; 28:316-324. [PMID: 30653030 DOI: 10.1097/pai.0000000000000731] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Granulomatous reaction is not uncommon in histopathology, with various etiologies in different organs and geographic regions. Lymphoma is one of the underlying causes of granuloma; and sometimes the neoplastic cells may be masked by the granulomatous reaction. In this report, we present our experience with 7 lymphoma cases of various histologic types with coexisting granuloma to show the diagnostic challenges. In all cases, a granulomatous reaction was simultaneously present with the neoplastic cells. The 7 cases included 3 cases of adult T-cell leukemia/lymphoma in the lymph node or skin including one coexisting with mycobacterial infection, 2 cases of classical Hodgkin lymphoma involving the liver, and 1 case each of systemic Epstein-Barr virus-positive peripheral T-cell lymphoma and a hepatic inflammatory pseudotumor-like follicular dendritic cell sarcoma. Three cases were initially misdiagnosed as reactive change or mycobacterial infection instead of lymphoma, and a wrong histologic lymphoma type was diagnosed in 1 case. In this report, we showed that granulomatous reaction might mask lymphomas of various histologic types; and a diagnosis of mycobacterial infection or sarcoidosis could not exclude the possibility of an underlying lymphoma. We emphasized the importance of detailed histologic examination with the aid of ancillary studies to reach a correct diagnosis and to avoid inappropriate management of the patients. Our study also broadened the spectrum of lymphoma types coexisting with granuloma.
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14
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Wee J, Sobhi S, De Boer B, Xu D. Liver rheumatoid nodules imitating liver malignancy: a rare occurrence. BMJ Case Rep 2020; 13:13/12/e234366. [PMID: 33328208 DOI: 10.1136/bcr-2020-234366] [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: 11/04/2022] Open
Abstract
We describe a case of a 61-year-old man with a background of rheumatoid arthritis who presented to the emergency department with a single-reported episode of haemoptysis on the background of an upper respiratory tract infection. A CT scan revealed an incidental 40 mm mass in upper right lobe of the liver abutting the diaphragmatic surface. A subsequent positron emission tomography scan confirmed the mass and raised the possibility of another lesion in the liver raising the suspicion of malignancy. The case was complicated by the inability to perform a fine needle aspiration biopsy due to the mass' proximity to the diaphragm. After discussion with the patient, it was decided to resect the affected liver segment. Histological analysis of the mass revealed localised necrotising granulomatous inflammation suggestive of a rheumatoid nodule, which is seldom reported in the literature.
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Affiliation(s)
- Jason Wee
- Faculty of Health and Medical Sciences, University of Western Australia, Crawley, Western Australia, Australia
| | - Salar Sobhi
- Faculty of Health and Medical Sciences, University of Western Australia, Crawley, Western Australia, Australia
| | - Bastiaan De Boer
- Faculty of Health and Medical Sciences, University of Western Australia, Crawley, Western Australia, Australia.,Anatomical Pathology, PathWest Laboratory Medical WA, Murdoch, Western Australia, Australia
| | - Dan Xu
- School of Public Health, Curtin University Bentley Campus, Perth, Western Australia, Australia .,Medical Education, Sun Yan-sen University of Medical Sciences, Guangzhou, China
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15
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Nussbaum EZ, Patel KK, Assi R, Raad RA, Malinis M, Azar MM. Clinicopathologic Features of Tissue Granulomas in Transplant Recipients: A Single Center Study in a Nontuberculosis Endemic Region. Arch Pathol Lab Med 2020; 145:988-999. [PMID: 33290524 DOI: 10.5858/arpa.2020-0271-oa] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— There is a paucity of literature about tissue granulomas in transplant patients. OBJECTIVE.— To characterize the clinicopathologic features of granulomas in this population and develop a clinically judicious approach to their evaluation. DESIGN.— We performed chart reviews of solid organ and allogeneic hematopoietic stem cell transplant recipients at Yale New Haven Hospital to identify patients with granulomas on biopsy obtained pathologic specimens. Pretransplant and posttransplant specimens were included. Data points included demographics, clinical presentation, epidemiologic risk factors, biopsy indication, location and timing, immunosuppression, histopathology, microbiology, and associated clinical diagnosis. Granuloma-related readmissions and mortality were recorded at 1, 3, and 12 months. RESULTS.— Biopsy proven granulomas were identified in 56 of 2139 (2.6%) patients. Of 56, 16 (29%) were infectious. Common infectious etiologies were bartonellosis (n = 3) and cytomegalovirus hepatitis (n = 3). Tuberculosis was not identified. Clinical symptoms prompted tissue biopsy in 27 of 56 (48.2%) cases while biopsies were obtained for evaluation of incidental findings or routine disease surveillance in 29 of 56 (51.8%). Presence of symptoms was significantly associated with infectious etiologies; 11 of 27 (40.7%) symptomatic patients compared with 5 of 29 (17.2%) asymptomatic patients had infectious causes. One death from granulomatous cryptogenic organizing pneumonia occurred. In pretransplant asymptomatic patients, no episodes of symptomatic disease occurred posttransplantation. CONCLUSIONS.— Granulomas were uncommon in a large transplant population; most were noninfectious but presence of symptoms was associated with infectious etiologies. Granulomas discovered pretransplant without clear infectious etiology likely do not require prolonged surveillance after transplantation. Symptomatology and epidemiologic risks factors should guide extent of microbiologic evaluation.
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Affiliation(s)
| | | | - Roland Assi
- Department of Surgery (Assi), New Haven, Connecticut
| | - Rita Abi Raad
- Department of Pathology (Raad), New Haven, Connecticut
| | - Maricar Malinis
- From the Department of Internal Medicine (Nussbaum, Malinis, Azar), New Haven, Connecticut.,The Section of Infectious Diseases (Malinis, Azar), New Haven, Connecticut
| | - Marwan M Azar
- From the Department of Internal Medicine (Nussbaum, Malinis, Azar), New Haven, Connecticut.,The Section of Infectious Diseases (Malinis, Azar), New Haven, Connecticut
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16
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Schmidt B, Sonne C, Nachtsheim D, Wohlsein P, Persson S, Dietz R, Siebert U. Liver histopathology of Baltic grey seals (Halichoerus grypus) over three decades. ENVIRONMENT INTERNATIONAL 2020; 145:106110. [PMID: 32937284 DOI: 10.1016/j.envint.2020.106110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 08/31/2020] [Accepted: 08/31/2020] [Indexed: 06/11/2023]
Abstract
The liver plays an important role in the metabolism and elimination of endogenic and exogenic lipid-soluble compounds. Multiple studies have shown that polychlorinated biphenyls (PCB) and dichlorodiphenyl trichloroethane (DDT) lead to morphological changes in liver cells. The aim of the present study was therefore to analyse liver changes over time in Baltic grey seals (Halichoerus grypus) and to correlate these with historical PCB and DDT contaminations. A total of 191 liver samples were collected between 1981 and 2015 in the Gulf of Bothnia and northern Baltic Proper. Six histological features were evaluated, including portal mononuclear cell infiltration, random mononuclear cell infiltration, lipid granulomas, hepatocellular fat vacuoles, hepatic stellate cells and mild multifocal bile duct hyperplasia accompanied by portal fibrosis. Three of the six lesions showed a significant correlation with age. Furthermore, a positive correlation between portal mononuclear cell infiltration and mild multifocal bile duct hyperplasia was found. Additionally, lipid granulomas were significantly correlated with hepatic stellate cells. More importantly, hepatic stellate cells and mild multifocal bile duct hyperplasia were correlated with adipose tissue (blubber) concentrations of ƩPCB, measured in a subsample (n = 34) of all individuals. No correlation with lesions and ƩDDT concentrations were found. These results show that age is an important factor for the development of these liver lesions, but PCBs burden may be an influencing factor. This is in agreement with previous studies of marine mammals in the Baltic Sea as well as in the Arctic. We therefore conclude that not only age of the animals, but also exposure to PCBs should be taken into account when understanding and evaluating the current health status of Baltic grey seals.
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Affiliation(s)
- Britta Schmidt
- Institute for Terrestrial and Aquatic Wildlife Research, University of Veterinary Medicine Hannover, Foundation, Werftstraße 6, D-25761 Büsum, Germany
| | - Christian Sonne
- Marine Mammal Research, Department of Bioscience, Aarhus University, Frederiksborgvej 399, P.O. Box 358, DK-4000 Roskilde, Denmark
| | - Dominik Nachtsheim
- Institute for Terrestrial and Aquatic Wildlife Research, University of Veterinary Medicine Hannover, Foundation, Werftstraße 6, D-25761 Büsum, Germany
| | - Peter Wohlsein
- Department of Pathology, University of Veterinary Medicine, Bünteweg 17, D-30559 Hannover, Germany
| | - Sara Persson
- Department of Environmental Research and Monitoring, Swedish Museum of Natural History, P.O. Box 50007, SE-104 05 Stockholm, Sweden
| | - Rune Dietz
- Marine Mammal Research, Department of Bioscience, Aarhus University, Frederiksborgvej 399, P.O. Box 358, DK-4000 Roskilde, Denmark
| | - Ursula Siebert
- Institute for Terrestrial and Aquatic Wildlife Research, University of Veterinary Medicine Hannover, Foundation, Werftstraße 6, D-25761 Büsum, Germany; Marine Mammal Research, Department of Bioscience, Aarhus University, Frederiksborgvej 399, P.O. Box 358, DK-4000 Roskilde, Denmark.
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17
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Almogairen SM. Abatacept induced granulomatous hepatitis with a sarcoidosis- like reaction: a blinded trial in mice. BMC Pharmacol Toxicol 2019; 20:26. [PMID: 31064410 PMCID: PMC6503540 DOI: 10.1186/s40360-019-0303-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 04/22/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Abatacept is increasingly used for rheumatoid arthritis (RA) and juvenile idiophathic arthritis (JIA) treatment. However little is known about the risk of hepatotoxicity. The aim of this study was to determine whether the inhibition of the T cell CD28 receptor by abatacept results in acute hepatitis in BALB/c mice. METHODS Twenty BALB/c mice were studied. Ten mice received subcutaneous (SC) injection of abatacept (0.25mg per 25g body weight per 0.03 ml normal saline) at 0, 2, 4 and 8 weeks. For the control group, 10 mice received a SC injection of normal saline (NS) (0.03 ml). At the 10th week post injection, the mice were sacrificed, and histopathological studies were conducted. RESULTS Of the abatacept-treated group, 3/10 mice died. Liver histology for the abatacept-treated group showed that 6/7 displayed histopathological changes in the lobular cellular infiltrates of eosinophils, lymphocytes and histiocytes, in addition to granuloma formation. In contrast, only minimal inflammation was observed in 3/10 mice in the control group (p=0.036). CONCLUSION Abatacept may play a role in inducing granulomatous hepatitis with a sarcoidosis-like reaction. Additional data including transaminases, antinuclear antibodies (ANA), Antimitochondrial antibodies (AMA) and other auto antibodies should be tested.
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Affiliation(s)
- Sultan M Almogairen
- Rheumatology Division, Department of Medicine, College of Medicine, King Saud University, P O Box 2925, Riyadh, 11461, Saudi Arabia.
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18
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Rzeczycki P, Yoon GS, Keswani RK, Sud S, Baik J, Murashov MD, Bergin IL, Stringer KA, Rosania GR. An Expandable Mechanopharmaceutical Device (2): Drug Induced Granulomas Maximize the Cargo Sequestering Capacity of Macrophages in the Liver. Pharm Res 2018; 36:3. [PMID: 30406478 DOI: 10.1007/s11095-018-2541-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/31/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE Drug-induced liver injuries (DILI) comprise a significant proportion of adverse drug reactions leading to hospitalizations and death. One frequent DILI is granulomatous inflammation from exposure to harmful metabolites that activate inflammatory pathways of immune cells of the liver, which may act as a barrier to isolate the irritating stimulus and limit tissue damage. METHODS Paralleling the accumulation of CFZ precipitates in the liver, granulomatous inflammation was studied to gain insight into its effect on liver structure and function. A structural analog that does not precipitate within macrophages was also studied using micro-analytical approaches. Depleting macrophages was used to inhibit granuloma formation and assess its effect on drug bioaccumulation and toxicity. RESULTS Granuloma-associated macrophages showed a distinct phenotype, differentiating them from non-granuloma macrophages. Granulomas were induced by insoluble CFZ cargo, but not by the more soluble analog, pointing to precipitation being a factor driving granulomatous inflammation. Granuloma-associated macrophages showed increased activation of lysosomal master-regulator transcription factor EB (TFEB). Inhibiting granuloma formation increased hepatic necrosis and systemic toxicity in CFZ-treated animals. CONCLUSIONS Granuloma-associated macrophages are a specialized cell population equipped to actively sequester and stabilize cytotoxic chemotherapeutic agents. Thus, drug-induced granulomas may function as drug sequestering "organoids" -an induced, specialized sub-compartment- to limit tissue damage.
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Affiliation(s)
- Phillip Rzeczycki
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan, 48109, USA
| | - Gi Sang Yoon
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan, 48109, USA
| | - Rahul K Keswani
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan, 48109, USA
| | - Sudha Sud
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan, 48109, USA
| | - Jason Baik
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan, 48109, USA
| | - Mikhail D Murashov
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan, 48109, USA
| | - Ingrid L Bergin
- Unit for Laboratory Animal Medicine, Medical School Office of Research, University of Michigan, 2800 Plymouth Road, Ann Arbor, Michigan, 48109, USA
| | - Kathleen A Stringer
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan, 48104, USA
| | - Gus R Rosania
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Michigan, 428 Church Street, Ann Arbor, Michigan, 48109, USA.
- University of Michigan College of Pharmacy, Ann Arbor, Michigan, 48109, USA.
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19
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Patedakis Litvinov BI, Pathak AP. Granulomatous hepatitis in a patient with Crohn's disease and cholestasis. BMJ Case Rep 2017; 2017:bcr-2017-220988. [PMID: 28882937 PMCID: PMC5589046 DOI: 10.1136/bcr-2017-220988] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2017] [Indexed: 12/21/2022] Open
Abstract
We describe a case of a 23-year-old woman with a history of Crohn's disease (CD), who initially presented with sepsis-like symptoms, subsequently developed severe cholestasis and following extensive inpatient workup was found to have non-caseating granulomas on her liver biopsy. Infectious aetiologies were excluded and the patient was treated with oral corticosteroids, which ameliorated but did not completely reverse the cholestasis. We review the differential diagnosis of hepatic granulomas and discuss the potential difficulties in establishing their exact aetiology in patients with CD.
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Affiliation(s)
| | - Amit P Pathak
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC, USA
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