PMC3961108_01
Imaging results of the patient's liver. (A) Computed tomography and (B) ultrasound findings on admission; and (C) computed tomography and (D) ultrasound findings after 1 year.
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Due to severe emaciation, subcutaneous or visceral fat was hardly observed (Fig. 1A). Abdominal US showed a homogeneous liver pattern and the liver/kidney contrast was not enhanced (Fig. 1B). Hu and the liver/spleen attenuation ratio was 1.11 (Fig. 1c), which were almost the same as the findings on admission. However, the volume of subcutaneous, visceral and trabecular fat tissues had markedly increased. Abdominal US (Fig. 1D) also showed no clear changes compared with that on admission.
Clinical course. PSL, prednisolone, UDCA, ursodeoxycholic acid; SNMC, Stronger Neo-Minophagen C; TPN, total parenteral nutrition; AST, aspartate aminotransferase; ALT, alanine aminotransferase; T-Bil, total bilirubin.
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Stronger Neo-Minophagen C (SNMC; Minophagen Pharmaceutical Co., Ltd., Tokyo, Japan) was administered every day to improve the AST and ALT levels, but was discontinued due to secondary aldosteronism on the eighth day, resulting in increases in AST and ALT levels (Fig. 2). SNMC treatment was resumed on the 13th day, and the serum AST and ALT levels were reduced to 74 and 150 IU/l, respectively. Therefore, 900 mg ursodeoxycholic acid (UDCA) was administered (Fig. 2). AST and ALT abnormalities were prolonged (Fig. 2). A previous study showed that the prognosis of patients that were similar to this case, who did not respond to Liver function was completely normalized on the 105th day (Fig. 2).
Microscopic findings of the liver biopsy specimen showed (A) steatosis, ballooning degeneration, (B) lobular inflammation, and (C) zone III perisinusoidal fibrosis on admission. (A and B) Hematoxylin and eosin staining (magnification, x40) and (C) Masson's trichrome staining (magnification, x20). (D) All morphological findings were ameliorated after 1 year (hematoxylin and eosin staining; magnification, x40).
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These histological findings were compatible with NASH and thus led to a diagnosis of severe acute exacerbation of secondary NASH with AN (Fig. 3A-C). The histological findings of the liver needle biopsy specimen (Fig. 3D) showed remarkable improvements in the fibrosis, steatosis, inflammation and hepatocyte ballooning.