PMC6749849_01
(A) Biochemical parameters of a patient with acute liver failure caused by metamizole. Liver transplantation was performed at day 16. (B) Liver biopsy obtained at day 4, Sirius Red staining. Collapse and condensation of the preexisting reticulin framework. (C) Liver biopsy obtained at day 4, hematoxylin and eosin staining. Dropout of extensive areas of liver cells with few surviving hepatocytes mainly in the periportal area and severe lobular inflammation. (D) Liver biopsy obtained at day 4, hematoxylin and eosin staining. The lobular infiltrate consists of mainly lymphocytes and histiocytes; eosinophils are not present.
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Blood analysis at admission revealed massive elevation of transaminases [aspartate transaminase (AST) 4,104 U/L and alanine aminotransferase (ALT) 3,375 U/L], bilirubin (195 micromol/L), cholestasis parameters [gamma-glutamyl transferase (GGT) 1,061 U/L and alkaline phosphatase 586 U/L), and impaired coagulation [international normalized ratio (INR) 1.4] ( Figure 2A ). The histological picture was characterized by the collapse and condensation of the preexisting reticulin framework ( Figure 2B ) and by the dropout of extensive areas of liver cells with only few, mostly periportal, surviving hepatocytes ( Figure 2C ). There was a severe lobular inflammation with lymphocytes and histiocytes, but no eosinophils ( Figure 2D ). As shown in  Figure 2A , transaminase levels peaked at day 5 and then decreased, probably reflecting complete loss of functional hepatocytes, and the serum bilirubin concentration increased. After transplantation, all blood values gradually returned to the normal range ( Figure 2A ), and 3 months after transplantation, all parameters of liver function had normalized.