Department of Medicine Department of Medicine Grand Rounds Grand Rounds Clinical VignetteClinical Vignette

Wednesday, March 4, 2009Wednesday, March 4, 2009

Peter Shue, M.D.Peter Shue, M.D.

Chief ComplaintChief Complaint

The patient is a 59 year old Chinese The patient is a 59 year old Chinese female presenting to a primary care female presenting to a primary care physician for a routine physical physician for a routine physical examination.examination.

History of Present IllnessHistory of Present Illness

20 years prior to presentation to clinic, the 20 years prior to presentation to clinic, the patient reported being diagnosed with patient reported being diagnosed with chronic hepatitis B infection. At that time, chronic hepatitis B infection. At that time, she was told that she did not require she was told that she did not require treatment but needed close monitoring. treatment but needed close monitoring.

She reported being in good health since She reported being in good health since that time; however she had not seen a that time; however she had not seen a physician in more than 5 years and came physician in more than 5 years and came to clinic requesting a full check-up.to clinic requesting a full check-up.

Additional HistoryAdditional History

Past Medical History: Past Medical History: – Chronic hepatitis B infectionChronic hepatitis B infection

Past Surgical History: Past Surgical History: – C-section x2C-section x2

Social History: Social History: – Immigrated from Hong Kong 25 years ago. Worked as a Immigrated from Hong Kong 25 years ago. Worked as a

seamstress but retired 5 years ago. seamstress but retired 5 years ago. – Denied any history of smoking, alcohol consumption or illicit drug Denied any history of smoking, alcohol consumption or illicit drug

use.use.Family History: non-contributoryFamily History: non-contributoryMedications: None, no herbal supplementsMedications: None, no herbal supplementsAllergies: NKDAAllergies: NKDAReview of Systems: non-contributoryReview of Systems: non-contributory

Physical ExamPhysical Exam

General: Overweight but healthy General: Overweight but healthy appearing female in no acute distressappearing female in no acute distress

VS: BP 140/85, P 67, RR 16, T 98, BMI 29VS: BP 140/85, P 67, RR 16, T 98, BMI 29

The physical exam was otherwise The physical exam was otherwise unremarkableunremarkable

LabsLabs

Hepatic Function Panel:Hepatic Function Panel:– AST 148, ALT 132AST 148, ALT 132– Remainder of values were within normal limitsRemainder of values were within normal limits

CBC:CBC:– WBC 4.9, Hgb 13.6, HCT 39.8, Plt 168WBC 4.9, Hgb 13.6, HCT 39.8, Plt 168

Basic Metabolic Panel:Basic Metabolic Panel:– Fasting glucose 92Fasting glucose 92– Remainder of values were within normal limitsRemainder of values were within normal limits

Lipid Panel:Lipid Panel:– Chol 117, Trig 61, HDL 55, LDL 50Chol 117, Trig 61, HDL 55, LDL 50

Coagulation Panel:Coagulation Panel:– All values were within normal limitsAll values were within normal limits

Working DiagnosisWorking Diagnosis

Chronic hepatitis B infectionChronic hepatitis B infection

Hospital CourseHospital CourseAdditional labs were sent off including:Additional labs were sent off including:– Hepatitis panel revealing:Hepatitis panel revealing:

HBcore Ab poHBcore Ab possHBsAg neg HBsAg neg HBsAb neg HBsAb neg HBeAb pos HBeAb pos HBeAg neg HBeAg neg HBV DNA PCR undetectableHBV DNA PCR undetectableHCV Ab neg, HCV PCR undetectableHCV Ab neg, HCV PCR undetectableHAV Ab pos, IgM negHAV Ab pos, IgM neg

– HIV ELISA negHIV ELISA neg– Anti-Mitochondrial Ab negAnti-Mitochondrial Ab neg– Anti-Smooth muscle Ab negAnti-Smooth muscle Ab neg– Anti-LKM negAnti-LKM neg– ANA negANA neg– Alpha 1-antitrypsin 148 (96-199)Alpha 1-antitrypsin 148 (96-199)– Ceruloplasmin 24 (21-53)Ceruloplasmin 24 (21-53)– Iron 137, TIBC 387, Ferritin 262Iron 137, TIBC 387, Ferritin 262– TSH 1.3TSH 1.3– AFP 4.8AFP 4.8

Hospital CourseHospital Course

Imaging studies were ordered:Imaging studies were ordered:– Abdominal U/S: Unremarkable liver parenchyma Abdominal U/S: Unremarkable liver parenchyma

and biliary system.and biliary system.– Triple phase Abd CT: Normal liver, biliary system Triple phase Abd CT: Normal liver, biliary system

and gallbladder.and gallbladder.

A liver biopsy was obtained, revealing:A liver biopsy was obtained, revealing:– Mild to moderate micro and macrovesicular Mild to moderate micro and macrovesicular

steatosis. Mild portal tract enlargement and steatosis. Mild portal tract enlargement and inflammation. No evidence of cirrhosis.inflammation. No evidence of cirrhosis.

Working DiagnosisWorking Diagnosis

Grade 1 non-alcoholic steatohepatitis Grade 1 non-alcoholic steatohepatitis (NASH).(NASH).

Follow-upFollow-up

The patient was subsequently started on The patient was subsequently started on amlodipine for hypertension and counseled about amlodipine for hypertension and counseled about weight loss. weight loss. The patient was loss to follow-up and returned to The patient was loss to follow-up and returned to her primary care physician 3 years later for a her primary care physician 3 years later for a routine check-up.routine check-up.The patient had no new complaints and was The patient had no new complaints and was otherwise feeling well. She attempted to lose otherwise feeling well. She attempted to lose weight but had been unsuccessful. She was taking weight but had been unsuccessful. She was taking no medications.no medications.Physical Exam and labs at that time were Physical Exam and labs at that time were unchanged from 3 years prior. unchanged from 3 years prior.

Follow-upFollow-up

Repeat Triple phase Abd CT: Lateral Repeat Triple phase Abd CT: Lateral segment of liver was enlarged with a nodular segment of liver was enlarged with a nodular contour. Right lobe was atrophic. Liver contour. Right lobe was atrophic. Liver morphology consistent with cirrhosis. morphology consistent with cirrhosis.

Repeat Liver biopsy: Moderate micro and Repeat Liver biopsy: Moderate micro and macrosteatosis with moderate portal and macrosteatosis with moderate portal and lobular inflammation. Fibrous septa was lobular inflammation. Fibrous septa was present consistent with transition to cirrhosis present consistent with transition to cirrhosis (Grade 2). (Grade 2).

Follow-upFollow-up

The patient subsequently had a positive The patient subsequently had a positive glucose tolerance test and was started on glucose tolerance test and was started on Pioglitazone.Pioglitazone.

A 6 month follow-up hepatic function panel A 6 month follow-up hepatic function panel revealed normalization of the revealed normalization of the transaminase levels transaminase levels

Final DiagnosisFinal Diagnosis

Nonalcoholic steatohepatitis leading to Nonalcoholic steatohepatitis leading to cirrhosis. cirrhosis.