A c t a P a t h . J a p . 29(2): 211-219, 1979

INTRAHEPATIC BILE DUCT DESTRUCTION IN A PATIENT WITH SARCOIDOSIS AND CHRONIC INTRAHEPATIC

CHOLESTASIS

Yasuni NAI(ANUMA*, Goroku OHTA*, Yoshikiyo YAMAZAKI**, and Kenji DOISHITA**

* 2nd Department of Pathology, School of Medicine, Kanazawa University, Kanazawa ** Department of Internal Medicine, Fukui Prefectural Hospital, Fukui

*** Department of Pathology, Fukui Prefectural Hospital, Fukui

(Received on June 9, 1978)

An autopsy case of sarcoidosis with chronic intrahepatic cholestasis for 2 and a half years was presented. Generalized distribution of noncaseathg epithelioid granulomas and positive Kveim test were consistent with sarcoidosis. Histological examination of the liver revealed extensive bile duct destruction similar to that seen in the liver of primary biliary cirrhosis. Destructive cholangitis found in the liver appeared to be responsible for long term intrahepatic cholestasis, and no sarcoid granulomas in the liver were found to destroy any bile duct. The possible relation in pathogenesis of the bile duct destruction between primary biliary cirrhosis and sarcoidosis was discussed. ACTA PATH. JAP. 29: 211-219,1979.

Introduction

Chronic intrahepatic cholestasis is a syndrome characterized by persistent jaundice, pruritus and elevated levels of serum alkaline phosphatase and cholesterol in the absence of extrahepatic bile duct obstruction. Although it is well known to be charac- teristic of primary biliary cirrhois (PBC),2,13,14 the syndrome in patients with sarcoidosis has been occasionally reported in the English literature^.^,^,^^,^^^^^

This report concerns a case of sarcoidosis with chronic intrahepatic cholestasis and destructive cholangitis in a comparison of bile duct destruction in the liver of PBC and ~ar~0idosis.1,2,',8,9,12,13,14

Methods Biopsy and autopsy materials were fixed in 10% formalin and embedded in paraffin. Sections

were stained with HE, Azan-Mallory, PTAH, PAS, PAP'S reticulum, Ziehl-Neelsen stain for acid- fast bacilli and orcein stain (Shikata)16. Special stains for copper was performed using the rubeanic acid method and the p-dimethylaminobenzyl rhodanine method. The liver copper value was measured by atomic absorption spectrophotometry.lO Tests for the antimitochondrial antibody,

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Mailing address: Y. NAKANUMA, M.D., 2nd Department of Pathology, School of Medicine, Kenazawa University, Takaramachi 13-1, Kanazawa 920, Japan. The content of this Paper Was presented a t the 67th Annual Meeting of The Japanese Patho- logical Society, Kumamoto, April, 1978.

21 1

212 SARCOIDO~IS WITH INTRAHEPATIC DESTRUCTIVE CHOLANGITIS Acta Path. Jap .

anti-smooth muscle antibody and antinuclear factors were examined by indirect immunofluorescent technique.

1. Examination of bile duct destruction by serial sections: 200 serial sections were cut from three paraffin blocks of the liver and a total of 600 sections were made and every fourth section was stained with HE. By sketching and tracing all bile ducts seen in liver sections, histological changes associated with duct disappearance were carefully examined.

2. As mentioned in our previous report,7 the bile duct and the artery with approximately equal size usually run parallel to each other within the portal tracts in normal livers. But in PBC livers and this case, the bile ducts were extensively destroyed and there were no bile ducts in the vicinity of the arteries in many portal tracts. It could, therefore, be expressed objectively by estimating the size and number of the arteries as landmarks for morphometrical examinations of disappeared bile ducts in the portal tracts. Namely, the ratio of the nmber of arteries accompanying corresponding bile ducts to the number of all arteries (a rate of parallelism) found in this case is calculated and is compared with that of controls. Thus the extent of bile duct destruction in the liver might be expressed quantitatively. Furthermore, our previous experiment indicated that ratios of the caliber of bile duct to that of the associated artery in normal livers and other liver diseases except PBC were relatively constant; the majority is between 0.7-0.8’. The caliber of the disappeared bile duct was assumed to be 0 . 7 4 . 8 times that of the artery with a lack of crresponding bile duct.

Detailed methods in the morphometrical experiment were shown in our previous report,7 and data of PBC, normal and other control livers were compared with those of the present case.

Classification of the intrahepatic biliary tree was made as follows: bile ductules were tubular structures present in the peripheral zone of the portal tract and had a caliber <20 p ; interlobular bile ducts were not present in the peripheral zone of the portal tract and had a caliber >20p. Septa1 bile ducts, which were larger than interlobular bile ducts, were surrounded by variable amounts of connective fiber band. It is sometimes very difficult to differentiate interlobular from septa1 bile ducts morphologically. Therefore, both ducts were called “bile ducts” and were classified according to their external diameter.

Morphometrical examination of bile ducts:

Case Report

The patient was a 26-year-old Japanese male industrial worker. Chief complaints were dyspnea and mild jaundice. There was no history of exposure to or ingestion of hepatotoxic materials. Clinical course : the patient complained of general malasia and chest compression in December 1969, followed by dyspnea. He was admitted to the Pukui Prefectural Hospital in March 1970. On physical examination, lymphnodes swelling of the bilateral colli was noted. Laboratory findings revealed an elevation of serum alkaline phosphatase (17.8 KA), serum transaminoferase (s-GOT 54.5, s-GPT 51), leucine aminopeptidase (695 u) and lactic dehydrogenase values (491 u). Roentgenogram of the chest showed bilateral hilar lymphadenopathy and diffuse reticular pulmonary shadowing. The Kveim skin test was positive, but the tuberculin test was negative. Biopsy of swollen cervical lymph node and the skin showed many non-caseating epithelioid granulomas as seen in those of sarcoidosis. Needle biopsy of the liver showed mild periportal fibrosis with the presence of the same granuloma and a moderate to mild degree of lymphocfiic idiltration, and an absence of bile plugs in the parenchyma. A diagnosis of sarcoidosis was made. Jaundice and pruritus developed in &rch 1973. ~borcc toryJ ind ings (July 1973 and September 1974, Table 1.) : Fluctuation of jaundice was noted for 2 and a half years till death. The serum cholesterol level remained within

29(2): 1979 Y. NAKANUMA d d 213

a normal range even in a phase of chronic intrahepatic cholestasis. Ascites and emacia- tion became marked, and he died of circulatory failure on November 1975. The antimitochondrial antibody and antinuclear factors were negative, but the anti-smooth muscle antibody was positive (1 :160).

Table 1. Laboratory Data

July 1973 September 1974

Liver function Total protein (g/dl) 7.4 7.4 Albumin (yo) 50 43.8 @,-glob- (%) 6.0 4.8 %-glob. (Yo) 8.0 7.5 @-glob. (%) 10.0 9.6 y-glob. (%) 26.0 34.0 MG 16.3 11.25 Bilirubin (mg/dl) 2.9 1.4

indirect 0.8 0.1 direct 2.1 1.3

TTT 10.9 14.3 ZTT 3.35 7.4 Cholesterol (mgkdl) 205 166 ALP (KA) 165 GOT 63 203 GPT 51.3 126 LDH 555 485 LAP (G.R) 705

RBC ( x 104) 432 385 WBC 2700 2800 Hb (g/W 14.8 11.0 Platelet 3.OX1O4 6.6X104

ESR (112 hrs) 315 25/47

Peripheral blood

Serological

CRP (+I RA (+I STS (-1 HBsAg (-1 a-Fetoprotein (-1

Autopsy and histo1ogi~lJindin.p: Severe emaciation and mild jaundice of the skin and bulbar conjunctivae were noted and ascites and pleural effusion were present. Cut- surface of the lung showed diffuse fibrosis with decreased air volume. Microscopically, mature and senescent non-caseating epithelioid granulomas were found in the alveolar walls and peribronchial tissues with mild degree of fibrosis. Systemic lymph nodes swelling was very marked and contained many senescent granulomas. Splenomegaly (695 g) was noted with the presence of many granulomas and chronic congestive changes. Similar granulomas were scattered in the testicles and skin. Special stains for acid- fast bacilli and fungi were negative in the lung and lymph node sections.

No evidence of stenosis and obstruction was detected in the extrahepatic bile duct and portal vein. The cut-surface of the liver was green-colored and swollen in appearance. The lobular pattern was distorted and miliary gray-colored nodules were

214 SARCOIDOSIS WITH INTRAHEPATIC DESTRUCTIVE CHOLANQITIS Acta Path. Jap.

29(2): 1979 Y . NARANUMA d d 215

dispersed throughout. Microscopically, hepatic lobules were moderately distorted by periportal fibrosis with mild infiltration of small round cells. Many non-caseating epithelioid granulomas were seen in the periportal tracts and the parenchyma (Fig. 1). Mild perilobular cholestasis and areas of feathery degeneration were present. Piecemeal necrosis with or without granulomas was occasionally found. Proliferation of atypical bile ductules was found in some of the periportal areas. Copper deposition in the perilobular hepatocytes was demonstrated by specific cytochemical stains (Fig. 2). The content of copper of the liver was 114.4 pglg dry liver (normal range 23.1 to 52.3 pglg dry liverlo)

It was very interesting to find many portal tracts devoid of bile ducts (Fig. 3) and some with a mild to marked degree of lymphocyt s accumulation (Fig. 4)) very similar

changes around the bile ducts, if present. Examination of bile duct destruction by serial sections revealed three types of his-

tological changes of the bile ducts just before their disappearance. (1) Destructive cholangitis of cellular reaction type (Fig. 5 ) : the bile duct was destroyed within an aggregation of small round cells. (2) Destructive cholangitis of edema tye (Fig. 6) : the bile duct disappeard within edematous periductal connective tissue, usually accompanied by a slight degree of fibrosis or mononuclear cellular infiltrations. (3) Destructive cholangitis of mild fibrosis type (Fig. 7): there was a slight degree of fibrosis around the bile duct about to disappear soon, associated with no cellular inflammatory changes. Mild epithelial proliferative changes, that is, papillary intraluminal projection or stratification found just before disappearance of the duct were also noted. Regressive changes of the epithelium, such as acidophilic, focal necrotic changes, or rupture of the epithelial layer were similar to the degree of those of PBC.819

The total number of the bile ducts showing the above mentioned destructive cholangitis was 27, and the frequency of the cellular reaction type was 1S.570 (5/27), edema type 7.4% (2/27) and fibrosis type 74.1% (20127). It was, however, noted that there was no bile duct destruction which was caused by a close approximation or duct invasion of sarcoid granulomas (RUDZKI et a1.)l3

Arteries seen in liver sections were divided into 4 groups according to their external diameter, and the extent of disappeared bile ducts were expressed by the size and number of originally associated arteries in the portal tracts. The rate of parallelism of every group of arteries with the bile ducts was constant (70-80%) in normal livers.' The rate in this case, however, was appreciably lower, but increased with the size of

to the destructive cholangitis seen in PBC livers: f 9$15 periductal fibrosis and edematous

Fig. 1. Many mature epithelioid granulomas are seen in the liver. Portal tract devoid of bile duct is extended by fibrous tissue. Autopsy liver, HE., x 52.

Fig. 2. Copper granules (4) accumulating in the perilobular hepatocytes. Autopsy liver, p- dimethylaminobenzylidene rhodanine stain for copper, counter-stained with Kernechtrot.

Fig. 3. Note a fibrously extended portal tract devoid of bile duct. Autopsy liver, HE., x 130. Fig. 4. Nonsuppurative cholangitis with acidophilic degeneration of the duct epithelium

This cholangitis is similar to the florid duct lesion

x 520.

and periductal round cell infiltration. of PBC. Autopsy liver, HE., x 130.

216 SARCOIDOSIS WITH INTRAHEPATIC DESTRUCTIVE CHOLANQITIS Acta Path. Jap.

Fig. 5. Cellular reaction type of destructive cholangitis. A bile duct with degenera- tive epithelium (+) present in infiltrat- ed mononuclear cells (left), and the duct disappears in these lesions (right). The interval of left and right figures is 40 p. Autopsy liver, HE., x 260.

Fig. 6. Edema type of destructive cholangi- tis. A bile duct with necrotic epithelium (+) disappears in the edematous connective tissue. The interval of left and right figures is 40 p. Autopsy liver, HE., X 260.

cholangitis of fibrosis type. A bile duct (+) disappears in the fibrous connective tis- sue (right and left). The interval of left and right figures is 40 ,u. Autopsy liver, x 260.

Fig. 7. Destructive

29(2): 1979 Y . NAKANUMA et d 217

arteries. Namely, the rate of parallelism of the arteries of 35-54 p in extrenal diameter was 29%, that of 55-74 ,u 47.3%, that of 7&94 p 69.6%, and that of more than 95 p 70.4%. It seemed, therefore, likely that there was extensive destruction of the bile ducts which originally had run parallel to the arteries of external diameter below 74 p and the presumed original caliber of such destroyed bile ducts could be calculated by the formula, discussed in the method, tobe below 50-60 p and the smaller the ducts, the more they were destroyed.

Discussion

The most prevalent hepatic involvement in sarcoidosis is asymptomatic granulomatous infiltration of which the only expression may be increased serum level of alkaline phosphatase and impaired bromsulfalein excretion. 5~6i13 However, patients in whom the predominant clinical manifestations of the illness have been the syndrome of chronic intrahepatic cholestasis, portal hypertension or both as were present in our case, have been infrequently reported in the English

Insidious onset of pruritus and chronic cholestatic jaundice, copper accumulation in the liver and serum, depressed hypersensitivity, and presence of non-caseating epithelioid granulomas in the liver were characteristics of PBC.1171~ i~ i~~ i~~ Some cases of sarcoidosis with chronic intrahepatic cholestasis, as seen in the present case, also revealed the same f e a t ~ r e s . 6 , ~ ~ PBC characteristically affects women of middle age, but sarcoidosis affects both sexes, in particular, male negros under 40 years.1~5~7-10112-16 Immunologically, anit-mitochondria1 antibody is detected in PBC, but negative in sarcoidosis. Reaction to Kveim antigen is negative in PBC, but usually positive in sarcoidosis. Furthermore, granulomas in sarcoidosis are ubiquitous, but those in PBC are usually restricted to the liver and occasionally in lymphnodes in the hepatic hilus. 6,13$4,15,17

The pathogenesis of the syndrome of chronic intrahepatic cholestasis of PBC appears to be extensive destruction of the intrahepatic bile ducts and the pathogenesis of their destruction has been demonstrated by us and others to result from destructive cholangitides including the florid duct lesion.112,7,8,9,~~,13,1~ While the pathogenesis of the syndrome of chronic intrahepatic cholestasis had remained unknown, RUDzKIl3 and MADDREY recently reported that there were extensive destruction of the intrahepatic bile duct in the livers of sarcoidosis with the syndrome and their destruction seemed to result in development of the syndrome. RTJDZKI~~ demonstrated that extensive bile duct destruction in the livers of sarcoidosis was caused by the periportal sarcoid granulomas themselves and the florid duct lesion, characteristically seen in PBC livers, was not present in the livers of sarcoidosis.

The interesting problem was an overlap of the intrahepatic destructive cholangitides in both PBC and the present case of sarcoidosis. Morphological examination of the intrahepatic bile duct using serial sections revealed the presence of three types of destructive cholangitides which all are usually seen in the livers of PBC and the absence of bilelduct destruction due to direct granulomatous invasion in the present

218 SA4RCOIDOSIS WITH INTRAHEPATIC DESTRUCTIVE CROLANGITIS ACkZ Path. Jap.

case. There seemed to be no or little fundamental difference in the morphology of destructive cholangitides between PBC and this case. The original caliber of destroyed bile ducts of this case was calculated to be below 50-60 p, and that of PBC was below 70-80 p,7 which was obtained from our previous experiment. So the extent of bile duct destruction was slightly greater in PBC than that of this case.

PBC and some cases of sarcoidosis were chronic progressive diseases of unknown etiology with intrahepatic non-caseating epithelioid granulomas and immunological a b n o r m a l i t i e ~ . ~ ~ ~ ~ ~ ~ ~ The possibility may exist that abnormal immune reactivity of the body might produce the granulomatous lesions and even determine the organ manifestation of these granulomatous diseases. Recent investigators believed that the ductal lesion of PBC occurs as a result of immune complex reaction in which specific antigen is unknown.18 This might be true of the destructive cholangitides found in the present case.

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29(2): 1979 Y. NAKANUMA el al 219

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