1. Recurrent hepatitis with Halogenated Anesthetics

2. History 36 y/o female resident in St Kitts HPI: PMH PSH
nausea, vomiting, epigastric discomfort, jaundice
Usual state of health until 1 week prior
One week prior to presentation 3rd Liposuction
Abnormal liver profile
Admitted at local hospital in St. Kitts
Transferred to JMH after worsening liver parameters
PMH
No known medical problems
PSH
Breast reduction in April 2007
First liposuction/breast scar removal June 2007
Second liposuction in April 2008

3. History Medications: SOCH: FAMH: Allergies: Diclofenac
No OTC or herbal supplementation
No wt reduction medications
SOCH:
Divorced with 3 children
Bank employee
Occasional alcohol/smokes/but no substance abuse
FAMH:
HTN
DM-2
No significant h/o liver diseases
Allergies:
Sulfa

4. Physical Examination General: sleepy but was able to answer questions
HEENT: jaundiced
Heart and lung clear
Abdomen: soft, tenderness in the RUQ, +hepatomegaly, no ascites
No edema, no skin rashes
Neuro: (grade 1-2 encephalopathy)

5. Lab data ANA/AMA: Negative AST: 734 u/L ASMA: 44.8 (nl <20)
Immunoglobulins were not processed
Hepatitis A, B and C negative.
HCV PCR <25 IU/ml
Alpha 1 AT: 108 (nl )
Ceruloplasmin: 16.7mg/dl (nl 20-60)
Pregnancy test: negative
Tox screen: not performed
Acetaminophen: negative
AST: 734 u/L
ALT: 348 u/L
Alk phos : 194 u/L
Total bilirubin: 19.6mg/dl
Direct bilirubin:14.6mg/dl
Total protein 7.1 g/dl
Albumin 3.2 g/dl
PT: INR 3.47.
WBC: 8.1, Hb: 10.3, Hct: 31.3, Plt: 324

6. Imaging U/S with Doppler study CT-head: no acute pathology CT-abdomen:
Peri-hepatic fluid
No intra/extra hepatic dilatation, gall stone
All vessels patent
CT-head: no acute pathology
CT-abdomen:
Minimal amount of fluid in abdomen
Edema in the sub-cutaneous tissue in the both inguinal areas consistent with recent surgery

7. Over the Next 72 hours Worsening of laboratory & clinical parameters
TBil: 21.8
INR: 7.95
Grade-4 encephalopathy
Patient underwent an emergent orthotropic liver transplantation

8. Explant
Sub-massive confluent centri-lobular necrosis of liver with chronic inflammatory infiltration
Above findings are consistent with fulminant hepatic failure 8

9. Post Op Liver Chemistries Pattern
Transplant
POD 6

10. Post Operative Liver function pattern
Transplant
POD 6

11. Differential Diagnosis
Hepatic artery thrombosis
Early Acute Cellular Rejection
Primary Non-function of Graft
Ischemic Hepatitis
Viral hepatitis
Drug induced hepatitis
Cold ischemic injury or Preservation Injury

12. Re-evaluation Donor status: 61 Y M
serology negative for viral infection
Donor tissue stains were negative for CMV/HSV and other viral etiology
No hypotensive episodes
Blood cx’s negative
No hepatic artery thrombosis
Meds
tacrolimus
levetiracetam
thymoglobulin
piperacillin/tazobactam
midazolom
dapsone
etomidate
labetolol
amphotericin B
During perioperative time
isoflurane
propofol. 12

13. Post Transplant – Day # 6
Liver biopsy - centri-lobular necrosis/mild acute rejection/bile duct injury 13

14. Post Transplant – Day # 14 Liver Biopsy – centri-lobular necrosis
No evidence of acute cellular rejection 14