1. Food Supplement associated Cholestasis

2. 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

3. 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

4. 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

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

6. 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.”

7. 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!!!!

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

9. Laboratory Data TOTAL PROTEIN 8.1 ALBUMIN LEVEL 3.6
TOTAL BILIRUBIN
AST (SGOT)
ALT (SGPT)
ALKALINE PHOSPHATASE
AFP
ABSOLUTE CD
HBsAg (+)
HBV DNA PCR IU/mL

10. Imaging: MRI Abdomen

11. 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

12. 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

13. 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