Aamer Agha, MD; Norman Sussman, MD Series Editor: Richard Goodgame, MD

Disclosures

May 09, 2007

Case Presentation

A 38-year-old white man presented with a 2-week history of abdominal pain and abdominal swelling.

He had a long history of very mild asthma. Two years ago an endocrinologist diagnosed and treated him for hypothyroidism and hypogonadism (magnetic resonance imaging [MRI] negative). He is an avid weight lifter and bodybuilder and takes numerous herbal medications and nutritional supplements (listed below). He applies a testosterone patch twice daily to his skin. He was in his usual state of health until 2 weeks ago when he noted the abrupt onset of abdominal pain. The pain was described as diffuse, varying slightly in intensity from time to time, and progressively increasing in intensity on a daily basis. There were no identifiable aggravating or alleviating factors. Associated with this pain was progressive, diffuse, symmetrical abdominal distension. Later, he noticed mild nausea and occasional dry heaves, and he reduced his food and fluid intake as a result. He noticed no fever, chills, night sweats, jaundice, respiratory, or genitourinary symptoms. One week ago he visited his primary care physician, who treated him for constipation with laxatives. The pain and swelling continued to progress, however. Two days ago his wife found him on the floor in intense pain. She immediately took him to another hospital where an abdominal ultrasound was performed. The study showed large-volume ascites and heterogeneity of the right lobe of the liver, which was consistent with fatty infiltration. A paracentesis yielded 2.6 L of clear, straw-colored fluid with the following laboratory results: serum-ascites albumin gradient (SAAG) of 1.4; < 100 nucleated cells per mcL; and normal amylase and triglyceride levels. Other test results included the following:

  • Negative viral serologies

  • Albumin = 3.1 mg/dL

  • Total bilirubin = 1.0 mg/dL

  • Aspartate aminotransferase (AST) = 199 U/dL

  • Alanine aminotransferase (ALT) = 281 U/dL

  • Alkaline phosphatase = 163 U/dL

  • International normalized ratio (INR) = 1.3

The patient was transferred to our hospital for further evaluation and treatment.

Past medical history is summarized in the history of the present illness. Additionally, there were no previous hospitalizations or operations, no history of blood transfusions or intravenous drug abuse, one exposure to intranasal cocaine 19 years ago, no tattoos or piercings, prior social drinking (1-2 beers per month) but stopped completely 6 months ago, and 7 sexual partners in his lifetime.

Medications and supplements included the following: testosterone patch twice daily; levothyroxine (thyroid hormone-replacement drug), 0.112 mg daily; albuterol inhaler, as needed; ephedrine hydrochloride tablets, as needed; Tribulus terrestris; zinc, 50 mg; starch blocker (contains white kidney bean extract); and several over-the-counter nutritional supplements containing mixtures of kava kava, passion flower, valerian root, Mucuna pruriens, Sumabolin, bioperine, N-acetylcysteine, and milk thistle.

Additional personal, social, and family history: The patient is married and works as a salesman in a chemical plant. He has never smoked and quit drinking as described above. He denies any current illicit drug use. There is no family history of liver disease or cancers.

Physical examination revealed the following: blood pressure, 112/79 mm Hg; heart rate, 108 beats per minute; respiratory rate, 21 breaths per minute; and temperature = 97.8° F. There is impressive muscle bulk but poor skin turgor in the upper part of the body. His mental status appears normal and he appears to be in no acute distress. There are no peripheral stigmata of chronic liver disease. No jaundice, palmar erythema, spider angiomata, gynecomastia, or asterixis is noted. There was pitting peripheral edema in the lower extremities to the knees. The peripheral pulses were normal except for tachycardia. No jugular venous distension was apparent. The heart was normal to palpation and auscultation. The chest exam was normal. The abdomen was distended and the flanks were bulging from ascites, but there was no abdominal tenderness. The liver and spleen were difficult to evaluate due to the ascites. Rectal, genital, and neurologic exams were normal.

Important laboratory studies at the time of admission to our hospital included the following:

  • Hemoglobin = 18.8 g/dL

  • White blood cell count = 20,160 cells/mcL

  • Differential = 0% bands, 86% polymorphonuclear leukocytes, 8% lymphocytes, 6% monocytes, 0% eosinophils

  • Normal electrolytes

  • Blood urea nitrogen = 15 mg/dL

  • Creatinine = 1.7 mg/dL

  • Total protein = 5.6 g/dL

  • Albumin = 3.4 g/dL

  • Total bilirubin = 1.3 mg/dL

  • Direct bilirubin = 0.8 mg/dL

  • Alkaline phosphatase = 165 U/L

  • ALT = 316 U/L

  • AST = 326 U/L

  • INR = 1.6

  • Iron = 2 mcg/dL

  • Total iron-binding capacity = 245 mcg/dL (percent saturation 0.8)

  • Ferritin = 199 mcg/dL

  • Thyroid-stimulating hormone = 15 mU/L

  • Thyroid peroxidase antibodies = 574 (normal <35)

  • HIV antibody-negative

  • Antinuclear antibody (ANA): 1:80

  • Anti-smooth muscle antibodies: negative

 

Diagnostic Question

At this point, before imaging studies are reviewed, which of the following diagnoses do you favor and why?

  • Acute autoimmune hepatitis

  • Acute drug-induced hepatitis

  • Hepatic sinusoidal obstruction syndrome (formerly called veno-occlusive disease)

  • Acute obstruction of the hepatic vein (Budd-Chiari syndrome)

View the correct answer.

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