PMC10075219_01
Photomicrographs of the liver biopsy. A - acute/subacute pattern of injury: there is a lymphocyte-predominant portal and lobular inflammation with spotty hepatocellular necrosis without significant ductal aggression (H&E, 10x); B - the "cholestatic hepatitis" injury with spotty necrosis, and acidophil bodies (H&E, 20x).
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In the lack of a specific diagnosis, a real-time ultrasound-guided percutaneous liver biopsy was performed, and the histologic evaluation showed acute/subacute hepatitis, with numerous foci of lobular necrosis, associated with moderate canalicular and intrahepatocytic cholestasis, predominantly in zone 3, without ductopenia or portal biliary reaction (Figures 1A and 1B).
Laboratory tests over time. ALP: alkaline phosphatase; ALT: alanine aminotransferase; AST: aspartate aminotransferase; AZA: azathioprine; GGT: gamma-glutamyl transferase; TB: total bilirubin; UDCA: ursodeoxycholic acid.
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The biochemical response was suboptimal (Figure 2), and a second liver biopsy was then performed two months later. The evolution of liver tests according to the treatment is displayed in Figure 2.
Photomicrograph of the second liver biopsy. A - extensive aggression of the bile duct, with cytoplasmic vacuolization, pyknotic nuclei and a plasma-cell rich infiltrate (H&E, 20x); B - there is a chronic destructive aggression of the bile duct, with numerous plasma cells and interface activity; C - portal and lobular granulomas are also present (H&E, 10x); D - confluent necrosis and pseudorosette hepatocellular regeneration (H&E, 20x).
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