2017 Annual Meeting

Evening Specialty Conference
Liver Pathology

Secrets from the Consult Files: Puzzling Cases Solved Piece by Piece

March 6 2017, 7:30pm to 9:30pm

Moderator:
Michael Torbenson, MD
Panelists:
Jospeh Misdraji, MD - Uta Drebber, MD - Steve Lagana, MD - Bita Naini, MD - Bill Cummings, MD

Pre-Meeting Materials

Case 1

Faculty:
Jospeh Misdraji, MD

Clinical History:

A 51 year-old HIV-positive homosexual man on HAART presents with two liver lesions on PET scan and MRI measuring 1.4 cm and 1.6 cm. Liver tests are elevated with an alkaline phosphatase of 745, AST 140, and ALT 398. He carries a history of Burkitt lymphoma of the submandibular region for which he is on chemotherapy. Because of concern for recurrent Burkitt lymphoma, a liver biopsy of one of the lesions is performed.

Morphological Findings (click to enlarge):

Figure 1 Low power scanning magnification
Figure 2 Medium power of cellular spindle area
Figure 3 Medium power of cellular spindle area
Figure 4 High power of spindle cell area
Figure 5 Medium power of spindle area with abscess
Figure 6 High power of spindle area
Figure 7 Medium power of hypocellular region
Figure 8 Background portal tract
Figure 9 Background portal tract

Case 2

Faculty:
Uta Drebber, MD

Clinical History:

A 49 year old male Caucasian patient developed within two weeks progressive malaise with nausea, coughing, vomiting, diarrhea, and worsening general state. Because of chest pain he was admitted to hospital. His past medical history was significant for adipositas (BMI 38), type 2 diabetes mellitus, hypertension and obstructive sleep apnea. The patient was on the following regular medication: Thyroxine, PPI, ACE inhibitor, beta receptor blocker, Thiazide diuretic, oral antidiabetics and Insulin. There was no significant history of alcohol drinking. His physical examination revealed normal vital signs and a slight sceral icterus. The remainder of the examination was normal. Cardiac infarction could be excluded. Due to ongoing elevation of AST, ALT and Bilirubin a liver biopsy was performed on day 3 after hospitalization.

Pertinent Laboratory Data:

Full blood count with Eosinophilia 14% Thromboplastin time (Quick) 52% AST 440U/L ALT 412 U/L GGT 785 U/L LDH 458 U/L CRP 3.8mg/dl Bilirubin, AP, TSH normal. Hepatitis Serology: negative for Hepatitis A; B; C. EBV serology without signs of reactivation. CMV IgG EIEA 1:32000 CMV IGM EIEA 2,5, Index <1

Morphological Findings (click to enlarge):

Figure 1
Figure 2
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Figure 4
Figure 5
Figure 6
Figure 7

Case 3

Faculty:
Steve Lagana, MD

Clinical History:

This is an elderly female with a history of extensive alcohol abuse. She presented to her primary care doctor for abdominal "fullness" and pain. A CT scan was obtained and demonstrated several (approximately 5) liver lesions, up to 5.7cm in greatest dimension. AFP was elevated (>2000). PET scan was essentially negative except for the liver lesions described above. A biopsy (CT guided) was obtained.

Pertinent Laboratory Data:

LFTs all within normal limits. Viral hepatitis work up negative.

Morphological Findings (click to enlarge):

Figure 1 H&E low
Figure 2 H&E 20x
Figure 3 H&E 40x
Figure 4 Mucin 20x
Figure 5 Reticulin 10x
Figure 6 Arginase-1 20x
Figure 7 Glypican-3 20x
Figure 8 p-CEA 60x
Figure 9 Cytokeratin 7 20x
Figure 10MOC-31 20x
Figure 11Albumin ISH 20x

Case 4

Faculty:
Bita Naini, MD

Clinical History:

10 year old previously healthy female was transferred from outside hospital with concerns for liver dysfunction. Patient was in her usual state of health until approximately 10 days prior to hospitalization when she started to complain of cough and low grade fever. She was prescribed 10 days of Keflex by primary medical doctor. Patient's mom had been giving her Zyrtec for congestion, Aspirin for fever, as well as an OTC cough herbal mixture with honey (Zarbees). Over the course of the week, she became increasingly fatigued and was "not acting like herself" and was taken to the ER.

Pertinent Laboratory Data:

  • AST 372 U/L
  • ALT 857 U/L
  • Alk Phos 219 U/L
  • INR 1.5
  • Ammonia 329 mcg/dL (normal 40-80 mcg/dL)

Morphological Findings (click to enlarge):

Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6
Figure 7

Case 5

Faculty:
Bill Cummings, MD

Clinical History:

The patient is a 56 year old female who speaks only Spanish. She presented with jaundice. Her past medical history included hypertension, hypothyroidism and type 2 diabetes mellitus. Review of systems showed no confusion or edema. There was no change in her abdominal girth, no bleeding symptoms and no weight loss or gain. She had experienced no itching or change in bowel habits. Medications included Levothyroxine, Metformin and Olopatadine. The physical exam was largely unremarkable with no evidence of asterixis or spider angiomas. Patient's weight was 169 pounds (76.6 kg). Height was not given but BMI was 32.98 kg/m2.

Pertinent Laboratory Data:

Laboratory values included a CBC notable for slight anemia and platelet levels in the 200K range; BUN 26 (H), creatinine 1.12 (H); Albumin 3.29 (L), Total protein 8.5 (N), total bilirubin 0.3 (N), alkaline phosphatase 139 (N), ALT 113 (H), AST 122 (H), glucose 97, INR 1.1, ANA 1:80. CT scan of the pelvis and abdomen did not show any liver lesions or signs of portal hypertension. A liver biopsy was performed. L = Low N = Within normal range H = High

Morphological Findings (click to enlarge):

Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6
Figure 7

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