Acute hemolytic crisis with fulminant hepatic failure as the first manifestation of Wilson's disease: a case report.

We report a 27-year-old woman who developed Coombs'' negative hemolytic anemia and fulminant hepatic failure as the initial manifestation of Wilson''s disease. Unmeasurably low level of serum alkaline phosphatase provided a clue to the diagnosis of Wilson''s disease. The diagnosis was established with the presence of Kayser-Fleischer ring, decreased serum ceruloplasmin level, and elevated urine and serum copper levels. In spite of repeated plasmapheresis, she died of multiorgan failure on the fifth hospital day.     

Anémie hémolytique récidivante révélatrice d’une maladie de Wilson (une nouvelle observation et revue de la littérature)

IntroductionThe liver and central nervous system are the usual targets of Wilson's disease, an inherited disorder of copper metabolism. Severe hemolytic anemia is an unusual complication of Wilson's disease.ExegesisWe report a case of Wilson's disease revealed by acute intravascular repeating hemolytic anemia associated with liver failure. The initially negative etiologic investigation was directed by occurred of liver failure. The genetic study allowed to discover an other similar case. The evolution was favourable under treatment with zinc sulfate and penicillamine.DiscussionDiagnosis of Wilson's disease must be considered in case of acute hemolytic anemia associated with liver failure in young adults.     

The effect of carbon tetrachloride on the copper-laden rat liver.

Copper is believed to be hepatotoxic in Indian Childhood Cirrhosis and Wilson''s disease. However, copper-loading causes only minimal hepatic damage in animal models. The hypothesis was therefore proposed that a second hepatic insult may precipitate or perpetuate liver injury in a copper-laden liver. In non-copper-dosed rats CCl4 (10 mmol/kg, i.p.) produced elevated serum AST (809 +/- 298 IU/l, normal 20 +/- 5) and ALT (295 +/- 157 IU/l, normal 6 +/- 1) and extensive liver cell necrosis, portal tract inflammation, fat deposition, and perilobular hepatocyte ballooning. In rats whose liver copper was elevated from 75 +/- 13 to 461 +/- 13 micrograms/g by oral copper supplementation, CCl4 produced much smaller increases in AST (492 +/- 80 IU/l) and ALT (172 +/- 57 IU/l) and mild focal liver cell necrosis. Fat deposition and perilobular vacuolation were not reduced. Prior copper-loading of rats unequivocally protected against the CCl4-induced liver injury. Triglyceride accumulation, however, was apparently unaffected. The possible interactions of copper with prostaglandin-mediated inflammation and with free-radical-induced liver damage are discussed.     

Wilson's disease: an analysis of 28 Brazilian children

OBJECTIVES:

Clinical-laboratory and evolutionary analysis of twenty-eight patients with Wilson''s disease.

METHODS:

Twenty-eight children (twelve females and sixteen males) with Wilson''s disease were evaluated retrospectively between 1987 and 2009, with a follow-up of 72 months (1 – 240 months). The clinical, laboratory, and histologic features at diagnosis were recorded at the end of the study.

RESULTS:

The median age at diagnosis was 11 years (2 – 18 years). Twelve patients were asymptomatic, seven had hepatitis symptoms, five had raised aminotransferase levels, three had hepatomegaly associated with neurological disorders, one had fulminant hepatitis with hemolytic anemia, and six patients presented with a Kayser-Fleischer ring. A histological analysis revealed that six children had chronic hepatitis, seven had cirrhosis, two had steatosis, one had portal fibrosis, and one had massive necrosis. The treatment consisted of D-penicillamine associated with pyridoxine for 26 patients. Adverse effects were observed in the other two patients: one presented with uncontrollable vomiting and the other demonstrated elastosis perforans serpiginosa. At the end of the study, all 26 treated patients were asymptomatic. Twenty-four of the patients were treated with D-penicillamine and pyridoxine, and two were treated with trientine and zinc sulfate. A liver transplant was performed in one patient with fulminant hepatitis, but the final patient died 48 hours after admission to the intensive care unit.

CONCLUSIONS:

Family screenings associated with early treatment are important in preventing Wilson''s disease symptoms and potentially fatal disease progression. The study suggests that Wilson''s disease must be ruled out in children older than two years presenting with abnormal levels of hepatic enzymes because of the heterogeneity of symptoms and the encouraging treatment results obtained so far.     

Metabolic disorders of the liver

Metabolic diseases could be inherited as inborn errors of metabolism or acquired. In this review we discuss some of the metabolic disorders likely to present in the adult population and in which liver biopsy could be indicated as part of diagnosis or treatment. These include iron overload/hemochromatosis, Wilson's disease, alpha-1-antitrypsin deficiency, Niemann–Pick's disease and Gaucher's disease with emphasis on characteristic or helpful histopathologic features. In this era of molecular and other non-invasive analyses, the role of liver biopsy for primary diagnosis has decreased but is still an important tool for supplementing clinical/molecular diagnosis, staging disease and as a guide to management. In addition to qualitative assessment, quantitative measurements of iron and copper per unit dry weight of liver tissue can be performed on paraffin-embedded blocks and should be considered in patients being treated for iron overload or being worked up for possible Wilson's disease respectively. Gaucher's disease and Niemann–Pick's disease are examples of lysosomal storage diseases that could present outside of the pediatric population; these diseases have fairly distinguishing features that could be used to triage which patients need additional enzyme or other assays for definitive diagnoses. While non-alcoholic steatohepatitis remains the commonest metabolic liver disease in adult population, the pathologist should also be aware of these other entities discussed in this review.     

Diagnostic histochemistry in hepatic pathology

Histochemistry has an important, continuing role in the current assessment of hepatic biopsies and resection specimens. The evaluation of connective tissue elements in the liver can be accomplished with such methods as the Masson trichrome, Snook reticulin, Vierhoff van Gieson, orcein, and Victoria blue stains. The results contribute to the diagnosis of acute and chronic hepatitis, submassive necrosis, venous outflow obstruction, steatohepatitis, and cirrhosis. Fat stains done on frozen sections of liver tissue are routinely performed in the evaluation of donor liver allograft biopsies. Iron stains such as Perls’ method and the Prussian blue technique contribute to the recognition of hemochromatosis and hemosiderosis. The rhodanine, orcein, and Timm stains for copper are used in the characterization of chronic cholestatic liver disease and Wilson's disease. Labeling of carbohydrate-based moieties in various disorders is accomplished with the digested and undigested periodic acid-Schiff method, and Congo red or crystal violet stains can be employed to detect amyloid deposition. Lastly, evaluations of the thickness of the cell plates and continuity of the reticulin framework, as seen with the Snook reticulin stain, can contribute to the diagnostic separation of benign from malignant hepatocellular neoplasms.     

An animal model for copper-associated cirrhosis in infancy

In Indian childhood cirrhosis (ICC) and related disorders of infancy, hepatic copper overload is associated with cirrhosis. Since copper administration alone has not been shown to induce cirrhosis in animals, synergy between copper and a second hepatotoxin has been suggested. This study investigates the ability of long-term exposure to copper and a pyrrolizidine alkaloid, retrorsine, to produce a model of copper-associated cirrhosis in rats. Groups of rat pups suckled on mothers fed 25 mg/kg diet retrorsine were weaned onto a diet containing 0·5 g/kg diet copper and retrorsine in varying dosage for 13 weeks. Histological similarities between the human disease and rats given copper with retrorsine 5 mg/kg diet included parenchymal destruction, fibrosis, nodular regeneration, and copper accumulation. There were significant histological differences from the human disorder, possibly attributable to inter-species variability or the critical timing or duration of exposure to hepatotoxins in the neonatal period. The hypothesis that ICC results from copper and a second hepatotoxin has not been disproved. Copyright © 1998 John Wiley & Sons, Ltd.     

Monolobar ductal plate malformation disease of the liver

We herein report a unique monolobar hepatic disease composed of Caroli's disease, peribiliary cysts, ductal plate malformations, peribiliary gland proliferation, hepatolithiasis, and portal phlebosclerosis with thrombi. A 73‐year‐old man underwent abdominal imaging, which revealed multiple segmental dilations of the left intrahepatic bile ducts. Polycystic kidney diseases were absent. Intrahepatic cholangiocarcinoma was suspected, and extended left lobectomy of the liver was preformed. Grossly, the hepatic left lobe was atrophic, and partly replaced by fibrous tissue. The intrahepatic bile ducts were dilated (Caroli's disease), and showed small calcium bilirubinate hepatoliths. Microscopically, the intrahepatic bile duct showed non‐obstructive segmental dilations (Caroli's disease), numerous peribiliary cysts, numerous ductal plate malformations, proliferation of intrahepatic peribiliary glands, and calcium bilirubinate hepatolithiasis. Portal veins showed phlebosclerosis with thrombi. Immunohistochemically, the various biliary epithelial cells were positive for cytokeratin (CK) 7, 8, 18, and 19, and for MUC6 and CD10. They were negative for MUC2 and MUC5AC. The ductal plate malformations were positive for fetal biliary antigen MUC1, but other biliary cell types were negative for MUC1. The present case resembles ‘monolobar Caroli's disease’. We believe that the present monolobular liver disease was congenital in origin.     

Chronic active liver disease. The range of histologic lesions, their response to treatment, and evolution

Histologic study of serial biopsy specimens in a prospective, controlled, double blind, randomized trial of treatment involving 63 patients with predefined clinical and biochemical criteria of severe chronic active liver disease revealed five different histologic patterns of hepatic injury on initial biopsy: chronic persistent hepatitis, chronic aggressive hepatitis, subacute hepatitis with bridging, subacute hepatitis with multilobular necrosis, and cirrhosis. The initial biopsies in the fatal cases revealed cirrhosis, subacute hepatitis with multilobular necrosis, or subacute hepatitis with bridging. Patients with subacute hepatitis with bridging and with multilobular necrosis more frequently revealed stigmata of viral hepatitis and more frequently developed cirrhosis than chronic aggressive hepatitis, regardless of treatment. The severe forms of hepatitis more frequently remitted to the histologic features of chronic persistent hepatitis in patients treated with prednisone and a combination of prednisone and azathio-prine than with azathioprine or placebo alone. Serial biopsy specimens frequently revealed changes in the histologic pattern before remission to chronic persistent hepatitis. Histologic progression to cirrhosis may occur by bouts of intralobular and multilobular necrosis as well as by piecemeal necrosis. Sampling error in needle biopsy of cirrhosis is so great that the condition either may be missed or may be impossible to accurately classify into portal and postnecrotic cirrhosis. Observations at autopsy always revealed postnecrotic cirrhosis characterized by extensive parenchymal loss and incomplete regeneration. We conclude that the evolution of any lesion is influenced by at least two factors: the original histologic pattern and the therapy applied.     

Lipomatous pseudohypertrophy of the pancreas: further evidence of advanced hepatic lesion as the pathogenesis

An 80-year-old Japanese man with liver cirrhosis was suspected of having lipomatous pseudohypertrophy of the pancreas on the basis of results of ultrasonography and a computed tomography scan. He eventually died of hepatic failure. He had no obesity, diabetes mellitus or pancreatic symptoms during his entire clinical course. Autopsy results confirmed lipomatous pseudohypertrophy of the pancreas, cholecystolithiasis, and postnecrotic liver cirrhosis associated with submassive hepatic necrosis was suspected. Although the pathogenesis of lipomatous pseudohypertrophy of the pancreas is not clear, the findings in the present case provide further evidence to support the hypothesis that advanced hepatic lesions cause this lesion.     

Serum beta 2-microglobulin (beta 2m) and anti-beta 2m antibody in chronic hepatitis

Serum beta 2-microglobulin (beta 2m) concentration is increased in pathological processes associated with lymphocyte activation. beta 2m and anti-beta 2m autoantibody (anti-beta 2m) determinations were made in the sera of 41 patients with chronic hepatitis and cirrhosis, respectively, in 19 with systemic lupus erythematosus (SLE) as well as in 27 healthy controls. A pathologically high beta 2m value was found in one-third of inactive persistent hepatitis, and in more than two-thirds of active hepatitis and postnecrotic cirrhosis cases. In SLE it occurred in 16 out of 19 cases. The beta 2m level was elevated mainly in HBV-negative and circulating immune complex-positive hepatic patients. Anti-beta 2m antibody occurred in one-third of chronic hepatitis, but only in one out of 13 cases in cirrhosis and in 12 out of nineteen patients with SLE. The results suggest that beta 2m and anti-beta 2m as in SLE may be further laboratory indicators of immunological activity in inflammatory hepatic disease.     

Electron Microscopic Detection of Copper in the Liver of Two Patients with Morbus Wilson by EELS and EDX

A 20-year-old male patient with morbus Wilson was liver transplanted because of terminal failure of liver function. The explanted liver showed a strong macronodular cirrhosis as typically seen in Wilson disease. There were visible granular accumulations in the hepatocytes after the rubeanic acid or rhodanine method for histochemical detection of copper. The electron microscopic studies on ultrathin sections revealed numerous electron-dense lysosomes and residual bodies. The elemental analysis in transmission electron microscope (TEM) with electron energy loss spectroscopy (EELS) and in scanning electron microscope (SEM) with energy dispersive x-ray analysis (EDX) showed copper-specific signals of electron-dense accumulations inside these dark lysosomes and residual bodies. In a second case, Wilson disease was diagnosed after autopsy of a 31-year-old patient by liver electron microscopy and EELS; strong electron-dense lysosomes and residual bodies with positive copper signals were found inside hepatocytes. For negative control, hepatocytes with iron accumulation after idiopathic hemochromatosis and liver cirrhosis were also analyzed by EELS in TEM, which showed strong iron, but only a few or no copper signals. Atomic absorption spectroscopy (AAS) in 16 liver samples of healthy and cirrhotic liver revealed only in both cases of Wilson disease a strong increased copper concentration higher than 100 µg Cu/g. The electron microscopic detection of copper-containing hepatocytic lysosomes is helpful for the diagnosis of early stages of Wilson disease in addition to the quantification of hepatic copper by AAS.     

Electron Microscopic Detection of Copper in the Liver of Two Patients with Morbus Wilson by EELS and EDX

A 20-year-old male patient with morbus Wilson was liver transplanted because of terminal failure of liver function. The explanted liver showed a strong macronodular cirrhosis as typically seen in Wilson disease. There were visible granular accumulations in the hepatocytes after the rubeanic acid or rhodanine method for histochemical detection of copper. The electron microscopic studies on ultrathin sections revealed numerous electron-dense lysosomes and residual bodies. The elemental analysis in transmission electron microscope (TEM) with electron energy loss spectroscopy (EELS) and in scanning electron microscope (SEM) with energy dispersive x-ray analysis (EDX) showed copper-specific signals of electron-dense accumulations inside these dark lysosomes and residual bodies. In a second case, Wilson disease was diagnosed after autopsy of a 31-year-old patient by liver electron microscopy and EELS; strong electron-dense lysosomes and residual bodies with positive copper signals were found inside hepatocytes. For negative control, hepatocytes with iron accumulation after idiopathic hemochromatosis and liver cirrhosis were also analyzed by EELS in TEM, which showed strong iron, but only a few or no copper signals. Atomic absorption spectroscopy (AAS) in 16 liver samples of healthy and cirrhotic liver revealed only in both cases of Wilson disease a strong increased copper concentration higher than 100 µg Cu/g. The electron microscopic detection of copper-containing hepatocytic lysosomes is helpful for the diagnosis of early stages of Wilson disease in addition to the quantification of hepatic copper by AAS.     

The morphology and morphogenesis of alcoholic cirrhosis of the liver]

A total of 42 biopsy specimens of the liver (blind and spot) in 32 patients with alcoholic cirrhosis of the liver were investigated. Morphological, portal, postnecrotic, and mixed types of cirrhosis were established. The portal type of cirrhosis is most common. On the basis of repeated analyses of biopsy materials of the liver it may be assumed that the development of cirrhosis of the liver of alcoholic etiology is connected with multiple attacks of acute alcoholic hepatitis. Abstention from alcohol consumption resulted in stifestations of exacerbation of cirrhosis. On the other hand, continuation of alcohol consumption contributed to progressing of cirrhosis, which following several attacks of alcoholic hepatitis, may change its morphological type: portal cirrhosis "transforms" into the postnecrotic or mixed type. The data obtained clarified the role of ethanol in progressing alcoholic cirrhosis of the liver, which according to the initial mecranisms of its development in postnecrotic, since every attack of acute alcoholic hepatitis is accompanied by coagulative (fields of alcoholic hyaline, or Mallory's bodies), or by colliquative (balloon dystrophy) necrosis of hepacytes.     

Perinatal hemochromatosis. Clinical, morphologic, and quantitative iron studies.

Three sibling and two isolated-case perinates (4 newborn, 1 stillborn) died with siderotic cirrhosis and widespread parenchymal siderosis, the latter similar to that seen in both hereditary and secondary hemochromatosis. Reticuloendothelial siderosis was absent, as occurs in primary hemochromatosis. Studies of iron metabolism were performed antemortem in two of the siblings and ante-, post- and internatally in their mother, who showed hyperferremia antenatally. The only finding in the affected family suggestive of hereditary hemochromatosis was the commonly associated HLA haplotype (A3, B7) in the mother and an infant. Liver morphology, including immunocytochemistry and ultrastructure, was similar in the 5 infants and suggested that liver disease commenced as massive necrosis in midfetal life. Histologic grading and chemical assays for iron and copper on liver and spleen of the 5 index cases were compared with 26 controls; placentas were compared with 12 control placentas. Hepatic iron concentration, but not hepatic copper concentration, was significantly increased in index cases, compared with controls. Hepatic iron to copper ratio was significantly increased in index cases, compared with controls, but this ratio was unaltered in spleen and placenta. Total hepatic iron, but not total hepatic copper, was significantly increased in index cases, compared with a subgroup of 11 controls of low gestational age, similar to the fetal stage when liver disease commenced in utero. The results suggest that, irrespective of the fetal liver disease being genetic or acquired, hepatic iron overload was directly involved in pathogenesis.     

Drugs and Nutrition

The importance of a balanced diet with proper quantities of foods cannot be overemphasized. Consideration must be given also to food''s digestion and absorption, transport to tissues, and utilization by cells. Interference during any stage of this process can result in nutritional deficiency. Certain foodstuffs can alter susceptibility to a drug, and certain drugs can affect the nutritional status of an individual.     

Acute liver failure associated with occupational exposure to tetrachloroethylene

Tetrachloroethylene is a chlorinated solvent that is primarily used in dry cleaning and degreasing operations. Although the hepatotoxicity caused by tetrachloroethylene has been well documented in literature, it is rarely considered as a cause of acute liver failure. We report a case of a 39-yr-old man who was admitted to our hospital for acute liver failure due to tetrachloroethylene exposure. Histological examination of the liver revealed massive hepatic necrosis, prominently, in zone 3 of the hepatic lobules. The patient underwent supportive treatment along with 3 sessions of plasmapheresis, and consequently, he presented a favorable outcome. Repeat liver biopsy performed 6 months after the patient's discharge showed architectural distortion with postnecrotic cirrhosis. Physicians should be aware of the possibility of acute liver failure induced by tetrachloroethylene. Early plasmapheresis can be effective for individuals with sufficient capacity for hepatocyte regeneration.     

Serum IgE levels in liver cirrhosis.

Abstract. Hypergammaglobulinemia is a well-known feature of liver cirrhosis, but studies on serum IgE in this setting are limited. The present study evaluates serum IgE concentration in a group of cirrhotic patients and examines their relationship with aetiological, clinical and analytical parameters (including liver function tests and hepatic phagocytic activity). The presence of specific IgE against common dietary antigens was also investigated. Total serum IgE was determined by enzyme immunoassay (EIA) in 52 cirrhotics (27 alcoholic and 25 non-alcoholic, including eight virus B and seven virus C-related cirrhosis, three primary biliary cirrhosis, three cryptogenic, three haemochromatosis and one Wilson's disease) and 34 healthy subjects (used as controls). Serum IgE (1U/ml) in contols was not significantly different from that of cirrhotic patients (median 42, range 2–726 vs median 86, range 2-> 1000, respectively) (P=NS). However, serum IgE among alcoholics (median 199, range 19- < 1000) was higher than that of controls (P < 0-001), virus B-related cirrhotics (median 25, range 3-< 1000) (P < 0-05), virus C-related cirrhotics (median 47, range 2-170) (P < 0-05), or nonalcoholic cirrhotics as a whole (median 23, range 2-< 1000) (P < 0.01). High IgE levels (≥ 170 1U/ml) were detected in 55.5% of alcoholics compared with only 12% of nonalcoholic cirrhotics (P < 0.01). Moreover, IgE levels were very high (> 1000 1U/ml) in six patients of the alcoholic group (22.2%) compared with only one non-alcoholic patient (4%). Increased serum IgE levels did not seem to be related to either parameters of liver function (serum bilirubin, albumin, prothrombin or Child-Pugh score), hepatic phagocytic function or other immunoglobulins. Skin-prick tests failed to demonstrate increased sensitization to eight common dietary antigens in the patients studied. On multivariate analysis, only the alcoholic aetiology of the disease correlated with high serum IgE levels. These data suggest that increased serum IgE might be a common and rather specific feature of chronic alcoholic liver disease.