A 34-year-old man is evaluated for elevated liver aminotransferases. The patient has no chronic medical conditions but has a history of injection drug use. Family history is notable for liver cirrhosis in his mother. Ultrasonography-guided liver biopsy is performed. Histopathology demonstrates marked panlobular mononuclear cell infiltration that cross into adjacent lobules. Occasional intensely eosinophilic round bodies are seen scattered amongst the hepatic parenchyma. Which of the following is the most likely cause of the latter histopathological finding in this patient?

Question

A 34-year-old man is evaluated for elevated liver aminotransferases.  The patient has no chronic medical conditions but has a history of injection drug use.  Family history is notable for liver cirrhosis in his mother.  Ultrasonography-guided liver biopsy is performed.  Histopathology demonstrates marked panlobular mononuclear cell infiltration that cross into adjacent lobules.  Occasional intensely eosinophilic round bodies are seen scattered amongst the hepatic parenchyma.  Which of the following is the most likely cause of the latter histopathological finding in this patient?

Quizplus · Accepted Answer

This patient who has a history of intravenous drug use likely has elevated aminotransferases due to acute viral hepatitis. Most cases are marked by significant panlobular lymphocytic inflammation, which may "bridge" into adjacent hepatic lobules due to collapse of the reticulin framework. Spotty areas of hepatocyte injury are typically seen. Necrotic hepatocytes appear ballooned with pale cytoplasm (ballooning degeneration). Alternatively, hepatocytes may undergo cytotoxic T-cell-mediated apoptosis due to the presence of viral antigens on the hepatocyte surface. These apoptotic cells appear as round, acidophilic (pink on hematoxylin and eosin staining) bodies known as Councilman bodies. Unlike acute viral hepatitis, chronic viral hepatitis is usually characterized by significant inflammation surrounding the portal triad (hepatic artery branch, portal vein branch, bile ductule). Hepatocytes usually have a ground-glass appearance (chronic hepatitis B virus) or an abundance of fat (chronic hepatitis C virus). Intravenous drug use is tightly linked to the transmission of hepatitis B and C virus. (Choice A) Toxin-mediated hepatic injury (eg, due to acetaminophen) usually results in centrilobular hepatocyte necrosis (ie, centered around central veins) due to oxidative damage. (Choice C) Hematochromatosis is characterized by the deposition of iron within hepatocytes, which results in the cells appearing pigmented when stained with Prussian blue. There is no fibrosis or inflammatory infiltrate. (Choice D) Mallory bodies are damaged cytokeratin filaments within hepatocytes that usually arise in patients with alcoholism. They appear as highly eosinophilic inclusions on microscopy. Alcohol-mediated liver injury is associated with fat deposition in hepatocytes, particularly in the centrilobular region. (Choice E) Aschoff bodies are small areas of granulomatous inflammation seen in the myocardium of patients with rheumatic heart disease. They are not seen in the liver. (Choice F) Stellate cells reside in the hepatic perisinusoidal space and can transdifferentiate into myofibroblasts in response to liver injury; they are the primary cells associated with liver fibrosis. However, this patient has an inflammatory infiltrate and Councilman bodies, not fibrosis. Educational objective: Intravenous drug use is a major risk factor for hepatitis B and C viral infection. Acute viral hepatitis is marked by panlobular inflammation and hepatocyte necrosis and ballooning. Cytotoxic T-cell-mediated signals also cause hepatocyte apoptosis with the formation of intensely eosinophilic Councilman bodies.

A 34-Year-Old Man Is Evaluated for Elevated Liver Aminotransferases