A 34-year-old man comes to the office due to 2 days of anorexia, nausea, and dark-colored urine. He travels frequently for business and recently returned from a trip to Mexico. The patient has a history of asthma and occasionally uses inhaled albuterol for symptom management. His temperature is 37.8 C (100.2 F), blood pressure is 125/70 mm Hg, and pulse is 94/min. Cardiopulmonary examination is normal. There is mild right upper quadrant abdominal tenderness with no guarding or rebound. Serologic testing for Entamoeba histolytica is negative. Which of the following findings is most likely to be seen on liver biopsy in this patient?

Question

A 34-year-old man comes to the office due to 2 days of anorexia, nausea, and dark-colored urine.  He travels frequently for business and recently returned from a trip to Mexico.  The patient has a history of asthma and occasionally uses inhaled albuterol for symptom management.  His temperature is 37.8 C (100.2 F), blood pressure is 125/70 mm Hg, and pulse is 94/min.  Cardiopulmonary examination is normal.  There is mild right upper quadrant abdominal tenderness with no guarding or rebound.  Serologic testing for Entamoeba histolytica is negative.  Which of the following findings is most likely to be seen on liver biopsy in this patient?

Quizplus · Accepted Answer

This patient's presentation with low-grade fever, anorexia/nausea, dark-colored urine, and right upper quadrant abdominal tenderness is highly suggestive of acute viral hepatitis. Hepatitis A virus (HAV) is most likely responsible as it is the most common cause of acute viral hepatitis in young adults and this patient has just returned from an endemic region. Although liver biopsy is not required to make the diagnosis, the hallmark histologic findings of acute viral hepatitis include hepatocyte necrosis and apoptosis with mononuclear infiltration. Hepatocyte necrosis is characterized by cellular swelling and cytoplasmic emptying (eg, "ballooning degeneration") likely caused by ATP depletion and disruption of the intermediate filament network. In severe cases, regions of adjacent lobules are interconnected by swaths of dead hepatocytes called "bridging necrosis." Hepatocyte apoptosis is characterized by cellular shrinkage and nuclear fragmentation with intense eosinophilia (eg, Councilman bodies) and is likely caused by mitochondrial oxidative damage. The presence of virally infected and dying hepatocytes promotes mononuclear inflammation in the sinusoids and portal tracts. (Choice A) Fibrinoid necrosis is characterized by the deposition of amorphous, proteinaceous material in the walls of blood vessels affected by immune vasculitis or malignant hypertension. (Choice C) Severe viral hepatitis can cause coagulative necrosis of hepatocytes. However, liquefactive necrosis classically occurs in the central nervous system due to enzymatic degradation of tissue. Amebic liver abscesses caused by Entamoeba histolytica infection may also produce liquefactive necrosis, but this is unlikely in the setting of negative serologic testing. (Choice D) HAV is not associated with an increased risk of hepatocellular cancer. However, hepatitis B and C infections, aflatoxin B exposure, and all other forms of chronic hepatocyte injury are associated with increased incidence of hepatocellular carcinoma. (Choice E) Nodular regeneration of hepatocytes is generally found in patients with cirrhosis due to chronic hepatitis. HAV does not cause chronic hepatitis, but HBV and HCV are associated with chronic hepatitis that can result in cirrhosis. Educational objective: Acute hepatitis due to most hepatotropic viruses causes hepatocyte ballooning degeneration and apoptosis with mononuclear cell infiltration. __________ References: Ballooned hepatocytes in steatohepatitis: the value of keratin immunohistochemistry for diagnosis. (http://www.ncbi.nlm.nih.gov/pubmed/18329127) Pathology of acute hepatitis A in humans. Comparison with acute hepatitis B. (http://www.ncbi.nlm.nih.gov/pubmed/6695857)

A 34-Year-Old Man Comes to the Office Due to 2