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May 27, 2019

Image challenge: A fierce battle in the liver to kill the enemy from the gut

What caused a 29-year-old woman with no significant medical history, and had recently returned from India, diarrhea, abdominal pain, anorexia and fever?

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Gastroenterology clinical image challenge: A 29-year-old woman was admitted to the emergency department with diarrhea, abdominal pain, and anorexia for two weeks and fever for five days. The patient was recently in India and returned two weeks prior. She had no significant medical history, and was not taking any medications or alcohol. She seemed ill and had right upper quadrant tenderness without a Murphy’s sign. Her body temperature was 38.0°C, but she reported a fever of 39.5°C at night.

Her hemoglobin level was 13.7 g/dL, with a leukocyte count of 3620/μL and platelet count of 106,000/μL. The aspartate aminotransferase level was 740 IU/L, with alanine aminotransferase of 410 IU/L, total bilirubin of 1.9 mg/dL, alkaline phosphatase of 206 IU/L, gamma-glutamyl transferase of 193 U/L and albumin of 3.6 g/dL. The prothrombin time was not prolonged, with an international normalized ratio of 1.07. Routine urinalysis and stool examination were unremarkable. Hepatitis B surface antigen, anti-hepatitis A virus IgM antibody, anti-hepatitis C virus antibody and anti-hepatitis E virus IgM antibody were negative. Serology for cytomegalovirus, Epstein-Barr virus and human immunodeficiency virus was negative. Peripheral blood smear for malaria and serology for dengue virus were negative. A contrast-enhanced abdominal computed tomography scan revealed enhancing wall thickening in the terminal ileum and ascending colon (Figure) with splenomegaly (12 cm), without evidence of focal hepatic lesion or cholangitis. 

Broad-spectrum antibiotics were started on admission. Blood cultures on the first and third days were positive for the specific bacterial pathogen. Percutaneous needle biopsy on the fifth day showed normal hepatic lobular architecture without fibrosis (Figure). Inflammatory nodules of various sizes were scattered in the lobules, although portal tracts were relatively intact (Figure). Numerous cells were in apoptosis near the inflammatory nodules (Figure). Immunohistochemical staining for CD68 showed numerous macrophages gathered in micronodules and sinusoids (Figure). Polymerase chain reaction for Mycobacterium tuberculosis using the biopsy specimen was negative. Two weeks after treatment with antibiotics, liver enzymes normalized and the patient was discharged.

What is the diagnosis? 

To find out the diagnosis, read the full case in Gastroenterology or download our Clinical Image Challenge app through AGA App Central, which features new cases each week. Sort and filter by organ, most popular or favorites. AGA App Central is available in both the Apple App Store and Google Play.

 

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