1. Fatal Liver Injury with a Food Supplement in Transplant Patient

2. History of Present Illness
38 y/o male computer specialist
Married, three children
Status post liver transplantation
2 month history
jaundice, elevated liver enzymes, weight loss, and fatigue

3. Past Medical History OLT 1981 – Wilson’s disease
OLT Dec – Graft dysfunction
Iron overload – Aug. 2006
treated with phlebotomy and chelating agent
HFE genotype negative

4. Medication Tacrolimus 1.5mg po bid Metoprolol 25mg po bid
Esomeprazole 40mg po qd
Ursodeoxycholic acid 600mg po tid
Dapsone 100mg po qweek
Temazepam 15mg po qhs
Deferasirox
No drugs or alcohol
Taking Açai berry juice supplement
Fruit juices, glucosamine
Esterified fatty acids

5. Investigations WBC 13.6, Hg 12.4, Plt 47, PT 22.8
Iron 242, TIBC 253, Sat 96%, Ferritin 1232
Albumin 3.0, glucose 93, Na 139, K 3.3, Cl 108
CO2 23 , BUN 14, Cr 1.1
TB 38.7, DB 37.3, AST 164, ALT 139
AlkP 160, GTTP 55
HAV, HBV, HCV, CMV, EBV negative
FK 9.6

6. Investigations Ultrasound MRCP/MRI Echocardiogram LVEF 55%
patent hepatic vein/arteries and portal vein
MRCP/MRI
no biliary dilatation
venous collaterals seen
patent vessels
normal appearing liver
splenomegaly
Echocardiogram LVEF 55%

7. -MARKED CANALICULAR AND CELLULAR CHOLESTASIS
-MARKED CANALICULAR AND CELLULAR CHOLESTASIS MILD PORTAL AND PARENCHYMAL CHRONIC INFLAMMATION ACCOMPANIED BY BALLOONING KUPFFER CELL HYPERPLASIA, AND APOPTOTIC BODIES REPRESENTING A PICTURE OF HEPATITIS.
-GLYCOGENATED NUCLLEI.
-NO DEFINITIVE ACUTE CELLULAR REJECTION

8. -MINIMAL PORTAL FIBROSIS, BUT PERICELLULAR FIBROSIS IS OBSERVED.

9. -MARKED IRON OVERLOAD IN HEPATOCYTES PREDOMINATELY OF PERIPORTAL LOCATION.

10. Course in Hospital No improvement Total bilirubin 35 PT 16.7
Developed hepatic encephalopathy
Ammonia 144
Nausea/vomiting
EGD showed esophageal varices
Listed for liver transplantation

11. Intra-operative Evidence of pancreatitis
Poor portal blood flow to donor graft
Cardiac arrest