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Lactic acidosis and hepatic steatosis caused by mitochondrial toxicity of nucleoside reverse transcriptase inhibitors (NRTI) is a rare cause of liver disease with a high mortality rate. This report describes a male, HIV-positive patient with a 4-week history of nausea, vomiting and abdominal pain. His medication consisted of prednisone 5 mg od (because of auto-immune thrombocytopenia), didanosine (for 2 years) and stavudine (for 3 months). Laboratory studies showed cholestasis and elevation of aminotransferases. Lactic level was not measured. Liver biopsy revealed steatosis and cholestatic hepatitis. In the absence of other causes of liver disease a probable diagnosis of stavudine-induced hepatic toxicity was made. After discontinuation of NRTI, he recovered completely. Because lactic acidosis had not been confirmed, stavudine was restarted and within 1 week the lactate level increased significantly. Therefore stavudine was discontinued again. One year later the patient is doing well on a double protease inhibitor regimen. In conclusion, clinicians treating patients with NRTI should be aware of the risk of lactic acidosis and hepatic steatosis. When this is suspected, all NRTI must be stopped. The diagnosis can be made when elevated lactate levels and hepatic steatosis are present in the absence of other causes of liver disease.
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PMID:Hepatic steatosis and lactic acidosis caused by stavudine in an HIV-infected patient. 1106 65

Studies have found that people with HIV have significant reductions in S-adenosylmethionine (SAMe). SAMe is an important ingredient in reactions used to make a substance that holds myelin, the coating on nerve fibers, together. SAMe also has been shown to have value in treating fibromyalgia and Alzheimer's disease. The drug may have potential use in fighting liver disease as well by increasing glutathione production and reducing the symptoms of cholestasis. Methionine, a substance made into SAMe by the body, might help improve HIV-related myelopathy. A study is currently enrolling patients with HIV to evaluate methionine's effectiveness in treating myelopathy. Side effects of methionine include nausea, vomiting, drowsiness, and irritability. Contact information is provided.
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PMID:SAMe as it ever was? 1136 83

We report the first case of acute cholestatic hepatitis induced by bupropion. This antidepressant was taken by a 49-year-old female as adjuvant treatment to stop smoking. After 20 days of bupropion, the patient presented a symptomatology characterized by asthenia, nausea and scleral icterus and biochemical analyses showed a dramatic increase in direct bilirubin (up to 28 mg/dl) and transaminases (up to 68-fold normal limits). Antinuclear antibodies were positive (title = 1:80; speckled pattern). Biochemical analyses and antinuclear antibodies were normal two years earlier. The histology showed a pattern of acute hepatitis with involvement of bile ducts and with features of centrolobular cholestasis. Treatment with methylprednisolone was commenced and continued for 20 days. Liver enzymes and bilirubin returned to normal within two months of withdrawal of bupropion and remained normal during the 4-month follow-up. Antinuclear antibodies also became negative. Other causes of liver damage were excluded. Considering the clinical diagnostic scale for hepatotoxic adverse drug reaction, our patient showed a score compatible with the final diagnosis of bupropion-related cholestatic hepatitis.
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PMID:Acute cholestatic hepatitis induced by bupropion prescribed as pharmacological support to stop smoking. A case report. 1178 18

We present a case of histologic changes resembling acute cellular rejection in a liver transplant patient treated with terbinafine. Approximately 5 years after orthotopic liver transplantation, a 51-year-old Hispanic man developed elevated liver enzyme levels. A biopsy sample was interpreted as acute cellular rejection, and the patient was treated with increased immunosuppression. Review of medications showed that the patient had been started on terbinafine approximately 4 weeks earlier for onychomycosis, and it was discontinued. A follow-up visit 2 weeks later revealed progressive jaundice, malaise, and nausea, and evaluation of a second liver biopsy sample revealed marked centrilobular cholestasis and severe bile duct damage, consistent with terbinafine hepatotoxicity. Although these histologic changes have been described in treated patients with both normal and abnormal livers, the potential for confusion with acute rejection in patients with hepatic transplantation has not previously been reported.
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PMID:Histologic changes resembling acute rejection in a liver transplant patient treated with terbinafine. 1261 88

Liver diseases specific of pregnancy, the most common hepatic complications of pregnancy, are always associated with a sometimes asymptomatic increase in serum aminotransferase activity. The most frequent of the liver diseases specific of pregnancy in normotensive pregnant women is cholestasis of pregnancy, the cause of generalised pruritus, and, in those with pregnancy-induced hypertension, preeclampsia which requires short-term cessation of pregnancy. Similar treatment is required by acute fatty liver of pregnancy the diagnosis of which must be done in the third trimester when recent polydipsia, nausea or vomiting occurs. Moreover, pregnancy increases the incidence and/or the severity of herpes simplex hepatitis (for which acyclovir therapy is urgently required) and hepatitis type E. Pregnancy may also unmask untreated cases of autoimmune hepatitis, Wilson's disease or Budd-Chiari syndrome.
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PMID:[Hepatic complications of pregnancy]. 1472 76

Pheochromocytoma is a rare tumor of chromaffin cells that secrete catecholamines and several cytokines. The clinical manifestations are protean and may include hypertension, weight loss, sweating, palpitation, headache, anxiety, tremor, nausea, vomiting, and hypercalcemia. The tumor can mimic many unrelated diseases, leading to significant delay and difficulty in diagnosis. We report a case of a 37-yr-old male admitted with jaundice, dark urine, fever, and signs of a systemic inflammatory response. Abdominal computed tomography revealed a heterogeneously enhancing tumor between the pancreatic tail and left kidney. There was no evidence of obstruction to bile flow, neoplastic involvement of the liver or bile ducts, or infectious etiology. The tumor was removed and found to be a pheochromocytoma. Immunohistochemical analysis revealed the presence of interleukin-1beta in the tumor cells. After surgery, the jaundice resolved without further treatment, leading us to the conclusion that it was a paraneoplastic phenomenon possibly related to interleukin-1beta production. We suggest that occult pheochromocytoma should be added to the differential diagnosis of unexplained intrahepatic cholestasis.
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PMID:Intrahepatic cholestasis as a paraneoplastic syndrome associated with pheochromocytoma. 1588 66

Gastrointestinal symptoms are extremely common during pregnancy. Increased levels of female sex hormones cause or contribute to symptoms such as heartburn, nausea, vomiting and constipation. If these symptoms do not respond adequately to lifestyle and dietary changes, drug therapy is often warranted to improve quality of life and to prevent complications. Physicians, therefore, need to be familiar with the low-risk treatment options available. Treatment of chronic conditions such as IBD or chronic liver disease during pregnancy can be demanding. In women with IBD, maintenance of adequate disease control during pregnancy is crucial. Most IBD drugs can be used during pregnancy, but the benefits and risks of specific drugs should be discussed with the patient. Liver diseases can be coincidental or pregnancy-specific. Pregnancy-specific liver diseases include not only benign disorders such as intrahepatic cholestasis of pregnancy, but also pre-eclampsia, eclampsia and HELLP syndrome (hemolytic anemia, elevated liver enzymes and low platelet count). Accordingly, the spectrum of therapeutic measures ranges from expectant management to urgent induction of delivery. During pregnancy, lamuvidine therapy for chronic hepatitis B can be continued; however, interferon and ribavirin therapy for chronic hepatitis C is contraindicated. This Review provides an overview of the spectrum and therapy of motility disturbances that occur during pregnancy, and discusses pregnancy-specific aspects of IBD and liver diseases.
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PMID:The spectrum and treatment of gastrointestinal disorders during pregnancy. 1925 5

We report the case of a patient who exhibited severe acute hepatitis with symptomatic cholestasis for more than 3 months and bile duct injury following the prescription of atorvastatin. After withdrawal the drug, the patient's wellbeing slowly improves and biological features normalize in 4 months. Therapy aimed at treating severe liver steatosis and hypercholesterolemia. Atorvastatin is a highly effective 3-hydroxy-3 methylglutamyl- coenzyme A reductase (statin) used to lower low-density lipoprotein. Reported frequent adverse events of the medication include nausea, depression, myalgia, abdominal pain and abnormal liver function tests. Although abnormal liver function tests is not an uncommon side effect of the medication, more serious liver injury is rare. In a recent literature review, about ten cases of serious hepatotoxicity have been documented. In the typical presentation, the duration of exposure prior to hepatic toxicity is variable. Liver injury is generally of the mixed type. A prolonged cholestasis for more than 3 months has been seldom reported. Morphological changes includes canalicular cholestasis, feathery degeneration but no cholangiolitis nor cholangitis under the form of cytological and inflammatory changes at the level of interlobular bile ducts. This case report provides further evidence that among statins, atorvastatin may be implicated in drug-induced liver injury and indicates for the first time that such liver injury may be followed by prolonged cholestasis and interlobular bile duct injury. Atorvastatin has thus to be added to the list of medication potentially responsible for bile duct injury.
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PMID:Severe acute cholestatic hepatitis with prolonged cholestasis and bile-duct injury following atorvastatin therapy: a case report. 1919 78

A 42-year-old morbidly obese patient (BMI 44.1 kg/m(2)) was admitted to our emergency room with upper abdominal pain, nausea, and cholestasis. Nine years ago, a vertical banded gastroplasty had been performed (former BMI 53.5 kg/m(2)) with a subsequent weight loss to BMI 33.0 kg/m(2). After regaining weight up to a BMI of 47.6 kg/m(2), 5 years ago a conversion to a gastric bypass was realized. A computed tomography of the abdomen showed an invagination of the remaining stomach into the duodenum causing obstruction of the orifice of common bile duct. The patient underwent an open desinvagination of the intussusception and resection of the remaining stomach. Gastroduodenal intussusception is rare and mostly secondary to gastric lipoma. To prevent this rare but serious complication, the remaining stomach could be fixed at the crura of the diaphragm, tagged to the anterior abdominal wall by temporary gastrostomy tube, or resected.
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PMID:After 3 years of starvation: duodenum swallowed remaining stomach. 1929 39

We report a case of acute-onset, long-lasting cholestasis induced by atorvastatin. This antihyperlipidaemic drug was taken for 40 days by a 72-year-old male as a treatment for his mixed dyslipidaemia. At that point, the patient presented with asthenia, nausea, painless icterus, acholic stools and hyperchromic urine with biochemical analyses showing a dramatic increase in bilirubin (total bilirubin 22 mg/dL; direct bilirubin 21 mg/dL) and alkaline phosphatase (up to 4-fold over the normal level) with less marked increases in transaminases. Liver histology showed a pattern of cholestasis with evident signs of cholangiolitis and damage of the interlobular bile ducts. Serum transaminase and bilirubin levels returned to normal within 5 months after atorvastatin withdrawal while alkaline phosphatase normalized after only 8 months. Scores on both the Maria and Victorino clinical scale for the diagnosis of drug-induced hepatitis and the Naranjo Adverse Drug Reaction Probability Scale indicated that atorvastatin was the probable cause of prolonged cholestasis in this patient. This is a rare case of cholestasis probably caused by atorvastatin and unusually characterized by bile duct damage.
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PMID:Atorvastatin-induced prolonged cholestasis with bile duct damage. 2015 93


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