Transcript Grandrounds Clinical Vignette

Department of Medicine
Grand Rounds
Clinical Vignette
Wednesday, March 4, 2009
Peter Shue, M.D.
Chief Complaint
The patient is a 59 year old Chinese
female presenting to a primary care
physician for a routine physical
examination.
History of Present Illness
20 years prior to presentation to clinic, the
patient reported being diagnosed with
chronic hepatitis B infection. At that time,
she was told that she did not require
treatment but needed close monitoring.
She reported being in good health since
that time; however she had not seen a
physician in more than 5 years and came
to clinic requesting a full check-up.
Additional History
Past Medical History:
– Chronic hepatitis B infection
Past Surgical History:
– C-section x2
Social History:
– Immigrated from Hong Kong 25 years ago. Worked as a
seamstress but retired 5 years ago.
– Denied any history of smoking, alcohol consumption or illicit drug
use.
Family History: non-contributory
Medications: None, no herbal supplements
Allergies: NKDA
Review of Systems: non-contributory
Physical Exam
General: Overweight but healthy
appearing female in no acute distress
VS: BP 140/85, P 67, RR 16, T 98, BMI 29
The physical exam was otherwise
unremarkable
Labs
Hepatic Function Panel:
– AST 148, ALT 132
– Remainder of values were within normal limits
CBC:
– WBC 4.9, Hgb 13.6, HCT 39.8, Plt 168
Basic Metabolic Panel:
– Fasting glucose 92
– Remainder of values were within normal limits
Lipid Panel:
– Chol 117, Trig 61, HDL 55, LDL 50
Coagulation Panel:
– All values were within normal limits
Working Diagnosis
Chronic hepatitis B infection
Hospital Course
Additional labs were sent off including:
– Hepatitis panel revealing:
HBcore Ab pos
HBsAg neg
HBsAb neg
HBeAb pos
HBeAg neg
HBV DNA PCR undetectable
HCV Ab neg, HCV PCR undetectable
HAV Ab pos, IgM neg
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HIV ELISA neg
Anti-Mitochondrial Ab neg
Anti-Smooth muscle Ab neg
Anti-LKM neg
ANA neg
Alpha 1-antitrypsin 148 (96-199)
Ceruloplasmin 24 (21-53)
Iron 137, TIBC 387, Ferritin 262
TSH 1.3
AFP 4.8
Hospital Course
Imaging studies were ordered:
– Abdominal U/S: Unremarkable liver parenchyma
and biliary system.
– Triple phase Abd CT: Normal liver, biliary system
and gallbladder.
A liver biopsy was obtained, revealing:
– Mild to moderate micro and macrovesicular
steatosis. Mild portal tract enlargement and
inflammation. No evidence of cirrhosis.
Working Diagnosis
Grade 1 non-alcoholic steatohepatitis
(NASH).
Follow-up
The patient was subsequently started on
amlodipine for hypertension and counseled about
weight loss.
The patient was loss to follow-up and returned to
her primary care physician 3 years later for a
routine check-up.
The patient had no new complaints and was
otherwise feeling well. She attempted to lose
weight but had been unsuccessful. She was taking
no medications.
Physical Exam and labs at that time were
unchanged from 3 years prior.
Follow-up
Repeat Triple phase Abd CT: Lateral
segment of liver was enlarged with a nodular
contour. Right lobe was atrophic. Liver
morphology consistent with cirrhosis.
Repeat Liver biopsy: Moderate micro and
macrosteatosis with moderate portal and
lobular inflammation. Fibrous septa was
present consistent with transition to cirrhosis
(Grade 2).
Follow-up
The patient subsequently had a positive
glucose tolerance test and was started on
Pioglitazone.
A 6 month follow-up hepatic function panel
revealed normalization of the
transaminase levels
Final Diagnosis
Nonalcoholic steatohepatitis leading to
cirrhosis.