Clinical History:
- A 44-year-old emergency medical technician has been feeling fatigued for months. He just doesn't have the same level of energy he used to have. He remembers that he had experienced an episode of jaundice about 10 years ago, but that episode resolved and he has been healthy since. A CBC reveals that he is not anemic. A chemistry panel reveals normal serum electroytes, but he has an elevated alanine aminotransferase of 132 U/L and aspartate aminotransferase of 113 U/L. He has a total bilirubin of 1.3 mg/dL with direct bilirubin of 0.8 mg/dL. His total protein is 5.4 g/dL with albumin of 2.9 g/dL. A liver biopsy is performed.
- What is suggested by the clinical laboratory and biopsy findings?
Hepatitis. Image 5.1 shows a typical gross appearance of a liver with ongoing hepatitis, with necrosis and lobular collapse seen as areas of hemorrhage and irregular furrows and granularity on the cut surface. Image 5.2 demonstrates a mononuclear inflammatory cell infiltrate that extends from portal areas and disrupts the limiting plate of hepatocytes which, in image 5.3 are seen to be are undergoing necrosis ("ballooning degeneration") with a small round Councilman body. This is the so-called "piecemeal necrosis" of chronic active hepatitis.
- What is the differential diagnosis?
Viral hepatitis is the most likely diagnosis. Hepatitis A is generally a mild, self-limited illness that rarely becomes an acute fulminant hepatitis. Hepatitis B and C can produce chronic disease. The latter two agents are more commonly parenterally acquired (transfusion of blood products, penetrating injuries in the health care setting, injection drug use, vertical transmission from mother to fetus) while hepatitis A is more often acquired via fecal-oral contamination. However, an identifiable risk may not be found in all cases.
Further History:
A hepatitis panel revealed the following:
| Test | Result |
| Hepatitis A antibodies, total | Positive |
| Hepatitis A, IgM | Negative |
| Hepatitis B surface antigen | Positive |
| Hepatitis B surface antibody | Negative |
| Hepatitis B core antibody | Positive |
| Hepatitis C antibody | Negative |
- How do you explain these additional laboratory findings?
The hepatitis A tests suggest that he has IgG antibodies from a remote, not current infection. The hepatitis B surface antibody is negative, though a positive value should be found in a person who received a hepatitis B vaccination. With chronic liver disease from hepatitis B, the surface antigen and core antibody are typically positive. The histologic findings are consistent with chronic hepatitis B. If a person with hepatitis B clears the infection, then hepatitis B surface antibody appears.
- What complications of this disease are illustrated by images 5.4 and 5.5?
The complications are those of chronic liver disease. In about two-thirds of patients, hepatitis B produces a subclinical disease. About 20% develop a clinically apparent hepatitis. About 5 to 10% go on to chronic hepatitis with both fibrosis and inflammation. The fibrosis can proceed to a macronodular cirrhosis. In this setting, the risk for hepatocellular carcinoma is increased. The fibrosis can proceed to a macronodular cirrhosis (image 5.5). In this setting, the risk for hepatocellular carcinoma (image 5.6) is increased.
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