1. NYU Medicine Grand Rounds Clinical Vignette Jay Desai, MD PGY3 January 19, 2011 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 66 year old African American man, who was referred to Gastroenterology Clinic for further work up of abnormal liver function testing Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. The patient was in his usual state of health of good health when he presented to his primary care physician _____ (when) for a routine health maintenance visit. On routine labs at that time, it was noted that his liver function tests were abnormal History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. Additional History Past Medical History: Coronary artery disease, complicated by a myocardial infarction in 2001 Recurrent oral Herpes Simplex Virus infections Past Surgical History: None Social History: No tobacco or illicit drug use, minor alcohol intake (how much) Sexually active with men and women, uses protection Family History: Grandfather died of liver disease (patient unfamiliar with further details) Father died of myocardial infarction in his 60s Mother alive, healthy Allergies: No Known Drug Allergies U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Additional History Medications: Aspirin 81mg daily Atenolol 25mg daily Simvastatin 20mg before bed Ranitidine 150mg twice daily as needed for heart burn Acyclovir 400mg four times daily as needed (requires it 3-4 times a year) Ibuprofen 400mg as needed for pain Levitra 20mg as needed Over the counter Medications: Vitamin B12, B6, C, E, Calcium, Rosehip, selenium, alfalfa, kelp, lecithin, ginseng, cod liver oil, bee pollen complex, green tea extract, red rice extract, Gingko extracts, Lysine. (Dosages unknown) U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Physical Examination Vital Signs: T 98.6 BP: 140/70 HR: 80 RR: 15 and O2 sat: 100% on Room Air. General: Overweight individual, resting comfortably on exam table, in no acute distress HEENT: anicteric sclera Abdomen: non tender, non distended, no fluid wave, positive bowel sounds, no hepatosplenomegaly. The remainder of the physical exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Laboratory Findings CBC: within normal limits Basic Metabolic panel: within normal limits Hepatic panel: AST 100 ALT 124 Alkaline Phosphatase 515 GGT 2030 Remainder of the hepatic panel was within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Hepatotoxicity secondary herbal medication intake Undisclosed excessive alcohol intake Infectious hepatitis Choledocolithiasis Primary sclerosing cholangitis Primary biliary cirrhosis Cholangiocarcinoma Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Visit 1: –The patient was advised to discontinue all herbal medications, and was advised to abstain from alcohol use. –A right upper quadrant ultrasound was obtained, which showed a normal liver, and no biliary dilatation. Clinic Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. Visit 2: – AST/ALT remained stable, but the patient’s alkaline phosphatase and GGT continued to rise. –Hepatitis serologies were sent and returned negativel –Magnetic Resonance Cholangiopancreatography (MRCP) was ordered. Clinic Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. The liver is normal in size, contour, and signal intensity. No focal hepatic lesion is identified. No enhancing mass or choledocholithiasis is identified. Mild prominence of portions of the intrahepatic biliary tree. Some of these dilated biliary ducts demonstrate subtle beading. Findings are suggestive of primary sclerosing cholangitis Magnetic Resonance Cholangiopancreatography U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Primary Sclerosing Cholangitis, causing asymptomatic elevations in liver function tests. Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS