Transcript schiff_case_04 - Blackwell Publishing

Recurrent hepatitis with Halogenated
Anesthetics
History
36 y/o female resident in St Kitts
HPI:
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nausea, vomiting, epigastric discomfort, jaundice
Usual state of health until 1 week prior
One week prior to presentation 3rd Liposuction
Abnormal liver profile
Admitted at local hospital in St. Kitts
Transferred to JMH after worsening liver parameters
PMH
– No known medical problems
PSH
– Breast reduction in April 2007
– First liposuction/breast scar removal June 2007
– Second liposuction in April 2008
History
Medications:
– Diclofenac
– No OTC or herbal supplementation
– No wt reduction medications
SOCH:
– Divorced with 3 children
– Bank employee
– Occasional alcohol/smokes/but no substance abuse
FAMH:
– HTN
– DM-2
– No significant h/o liver diseases
Allergies:
– Sulfa
Physical Examination
General: sleepy but was able to answer
questions
HEENT: jaundiced
Heart and lung clear
Abdomen: soft, tenderness in the RUQ,
+hepatomegaly, no ascites
No edema, no skin rashes
Neuro: (grade 1-2 encephalopathy)
Lab data
AST: 734 u/L
ALT: 348 u/L
Alk phos : 194 u/L
Total bilirubin: 19.6mg/dl
Direct bilirubin:14.6mg/dl
Total protein 7.1 g/dl
Albumin 3.2 g/dl
PT: 32.2. INR 3.47.
WBC: 8.1, Hb: 10.3, Hct:
31.3, Plt: 324
ANA/AMA: Negative
ASMA: 44.8 (nl <20)
Immunoglobulins were not
processed
Hepatitis A, B and C
negative.
HCV PCR <25 IU/ml
Alpha 1 AT: 108 (nl 90200)
Ceruloplasmin: 16.7mg/dl
(nl 20-60)
Pregnancy test: negative
Tox screen: not performed
Acetaminophen: negative
Imaging
U/S with Doppler study
– Peri-hepatic fluid
– No intra/extra hepatic dilatation, gall stone
– All vessels patent
CT-head: no acute pathology
CT-abdomen:
– Minimal amount of fluid in abdomen
– Edema in the sub-cutaneous tissue in the both
inguinal areas consistent with recent surgery
Over the Next 72 hours
Worsening of laboratory & clinical parameters
– TBil: 21.8
– INR: 7.95
– Grade-4 encephalopathy
Patient underwent an emergent orthotropic liver
transplantation
Explant
Sub-massive confluent centri-lobular necrosis of liver with
chronic inflammatory infiltration
Above findings are consistent with fulminant hepatic
failure
Post Op Liver Chemistries Pattern
4000
3500
Transplant
3000
POD 6
2500
SGOT
SGPT
Alk.Phos
2000
1500
1000
500
28
25
26
21
23
19
15
17
11
13
9
7
5
3
1
0
Post Operative Liver function pattern
25
20
Transplant
Tbilirubin
INR
Creatinine
POD 6
15
10
5
28
25
22
19
16
13
10
7
4
1
0
Differential Diagnosis
Hepatic artery thrombosis
Early Acute Cellular Rejection
Primary Non-function of Graft
Ischemic Hepatitis
Viral hepatitis
Drug induced hepatitis
Cold ischemic injury or Preservation Injury
Re-evaluation
Donor status:
– 61 Y M
– serology negative for viral
infection
– Donor tissue stains were
negative for CMV/HSV and
other viral etiology
No hypotensive episodes
Blood cx’s negative
No hepatic artery thrombosis
Meds
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tacrolimus
levetiracetam
thymoglobulin
piperacillin/tazobactam
midazolom
dapsone
etomidate
labetolol
amphotericin B
During perioperative time
– isoflurane
– propofol.
Post Transplant – Day # 6
Liver biopsy - centri-lobular necrosis/mild acute rejection/bile duct injury
Post Transplant – Day # 14
Liver Biopsy – centri-lobular necrosis
No evidence of acute cellular rejection