Contributed by Randall G. Lee, M.D.
PATIENT HISTORY: Per referral letter, the patient is a middle aged male. S/P orthotopic liver transplant for HCV cirrhosis. R/O rejection/sepsis. Four weeks post transplant, his enzymes increased. Biopsies x 2. Treated with steroid recycle between biopsies without result. Transaminases increased (AST approximately 1200); canaliculars increased (approximately 400 range). Review of outside material.

Final Diagnosis (Case 19)

PART 1: ALLOGRAFT LIVER, NEEDLE BIOPSY -
  1. ACTIVE LOBULAR HEPATITIS (See Microscopic Description).
  2. MINIMAL EVIDENCE OF ACUTE REJECTION.

PART 2: ALLOGRAFT LIVER, NEEDLE BIOPSY -

  1. ACTIVE LOBULAR HEPATITIS WITH MINIMAL MIXED STEATOSIS.
  2. PERIPORTAL AND MID ZONAL HEPATOCYTE SWELLING, CONSISTENT WITH STEROID THERAPY.
  3. NO EVIDENCE OF ACUTE REJECTION.

COMMENT:
Although significant bile duct loss is not noted, the changes of chronic duct injury raise the possibility of early chronic rejection. In some instances, similar duct changes can be associated with chronic hepatitis C, but they are typically focally distributed in that setting. Correlation with liver enzymes (including the GGTP) is necessary.

Previous Biopsies on this Patient:
NONE

TPIS Related Resources:
Liver Allograft Rejection Grading
Liver Transplant Topics


Gross Description - Case 19

The specimen consists of two (2) consult slides, Part 1 (1) and Part2 (1), with accompanying surgical pathology reports.


Microscopic Description - Case 19

The initial biopsy demonstrates a mild lobular hepatitis characterized by numerous scattered acidophilic bodies together with a lobular inflammatory infiltrate that comprises mononuclear cells, hypertrophy Kupffer cells, and scattered eosinophils. No viral inclusiona are identified. There is minimal macrovesicular steatosis. The portal tracts generally demonstrate mild ductular proliferation and a sparse mononuclear infiltrate. One portal tract displays a more pronounced mononuclear infiltrate associated with bile duct injury. This finding is indicative of acute rejection, but, given the involvement of only one tract, it qualifies for a grade of minimal or indeterminant acute rejection. Overall the changes indicate an active lobular hepatitis, and cytomegalovirus, other extrahepatic infections, and early recurrent hepatitis C should be considered as possibilities. By report, immunostains for CMV were negative.

The second biopsy demonstrates similar lobular features with numerous acidiophilic bodies. The degree of lobular inflammation is less, and this, along with the hepatocyte swelling centered on the periportal region, correlates with the steroid therapy given. No evidence of acute rejection is seen, and no viral inclusions are identified. By report, CMV immunostains are again negative. Again, the changes (in the absence of other infectious agents) suggest the possibility of early recurrent hepatitis C.


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