Food Supplement associated Cholestasis

History of Present Illness 46 y/o HIV/AIDS (CD4 154, Viral Load 4,000 November 2005, never treated) HBV + (never treated) p/w 10 days of epigastric pain and diarrhea (6-7x/day) Now evolved into clay colored stools and dark urine

History of Present Illness 2 days prior to the onset of symptoms, the patient had completed a 10 day course of doxycycline a “lump under his arm” Admits to having lost approximately 50 pounds in the last 9 weeks secondary to mild nausea

Past Medical History HIV/AIDS – Dx’d 1995, CD4 154 VL 4,000 never on HAART, never on prophylaxis PCP, Oral thrush, sepsis secondary to CAP 10 years ago. No opportunistic infections since that time Hepatitis B virus – never treated

Medications Taking no prescription medications Using RIPPED FAST for the past 3 months

Ripped Fast “To achieve perfect definition: get rid of the subcutaneous fat that hides the natural muscle.” “Ripped FastTM is manufactured using only select natural and pharmaceutical grade raw mateirals for optimum purity and absorption. Recommeded by doctors.”

Medications Contents: Serving Size 2 Capsules Servings Per Bottle 60 MaHuang (mg) 334 Kola Extract (mg) 1000 L-Carnitine (mg) 100 Chromium picolinate 200mc Only $11.75!!!!

Physical Examination General: : Jaundice, Mild distress, thin, ill appearing, A&Ox3 Abd: s/nd, tender on palpation, most pronounced at the epigastrum.

Laboratory Data TOTAL PROTEIN 8.1 ALBUMIN LEVEL 3.6 TOTAL BILIRUBIN 23.4 AST (SGOT) 110 ALT (SGPT) 94 ALKALINE PHOSPHATASE 541 AFP 0.96 ABSOLUTE CD4 698 HBsAg (+) HBV DNA PCR 243 IU/mL

Imaging: MRI Abdomen

Percutaneous Liver Biopsy Liver Parenchyma: Lobular disarray, eosinophils, neutrophils, mild portal mixed inflammatory infiltrate Intracellular and canalicular cholestasis, foamy degeneration of the hepatocytes, paucity and injury of bile ducts Immunostains: Negative Trichrome stain: mild pericellular portal and periportal fibrosis

Liver Biopsy Impression: Eosinophilic inflammation: Suggests possible drug related effect Bile duct inflamation, ductopenia and chronic cholestatic changes (foamy hepatocyte degeneration ) raises the possibility of HIV cholangiopathy

Hospital Course The patient remained in the hospital for 4 days during which time his symptoms improved LFTs improvement (AST: 100, Alt:90, ALK Phos 200, Total bilirubin: 15) The patient was discharged