1. Department of Medicine Grand Rounds Clinical Vignette Wednesday, March 4, 2009 Peter Shue, M.D.

2. Chief Complaint The patient is a 59 year old Chinese female presenting to a primary care physician for a routine physical examination.

3. History of Present Illness 20 years prior to presentation to clinic, the patient reported being diagnosed with chronic hepatitis B infection. At that time, she was told that she did not require treatment but needed close monitoring. She reported being in good health since that time; however she had not seen a physician in more than 5 years and came to clinic requesting a full check-up.

4. Additional History Past Medical History: –Chronic hepatitis B infection Past Surgical History: –C-section x2 Social History: –Immigrated from Hong Kong 25 years ago. Worked as a seamstress but retired 5 years ago. –Denied any history of smoking, alcohol consumption or illicit drug use. Family History: non-contributory Medications: None, no herbal supplements Allergies: NKDA Review of Systems: non-contributory

5. Physical Exam General: Overweight but healthy appearing female in no acute distress VS: BP 140/85, P 67, RR 16, T 98, BMI 29 The physical exam was otherwise unremarkable

6. Labs Hepatic Function Panel: –AST 148, ALT 132 –Remainder of values were within normal limits CBC: –WBC 4.9, Hgb 13.6, HCT 39.8, Plt 168 Basic Metabolic Panel: –Fasting glucose 92 –Remainder of values were within normal limits Lipid Panel: –Chol 117, Trig 61, HDL 55, LDL 50 Coagulation Panel: –All values were within normal limits

7. Working Diagnosis Chronic hepatitis B infection

8. Hospital Course Additional labs were sent off including: –Hepatitis panel revealing: HBcore Ab pos HBsAg neg HBsAb neg HBeAb pos HBeAg neg HBV DNA PCR undetectable HCV Ab neg, HCV PCR undetectable HAV Ab pos, IgM neg –HIV ELISA neg –Anti-Mitochondrial Ab neg –Anti-Smooth muscle Ab neg –Anti-LKM neg –ANA neg –Alpha 1-antitrypsin 148 (96-199) –Ceruloplasmin 24 (21-53) –Iron 137, TIBC 387, Ferritin 262 –TSH 1.3 –AFP 4.8

9. Hospital Course Imaging studies were ordered: –Abdominal U/S: Unremarkable liver parenchyma and biliary system. –Triple phase Abd CT: Normal liver, biliary system and gallbladder. A liver biopsy was obtained, revealing: –Mild to moderate micro and macrovesicular steatosis. Mild portal tract enlargement and inflammation. No evidence of cirrhosis.

10. Working Diagnosis Grade 1 non-alcoholic steatohepatitis (NASH).

11. Follow-up The patient was subsequently started on amlodipine for hypertension and counseled about weight loss. The patient was loss to follow-up and returned to her primary care physician 3 years later for a routine check-up. The patient had no new complaints and was otherwise feeling well. She attempted to lose weight but had been unsuccessful. She was taking no medications. Physical Exam and labs at that time were unchanged from 3 years prior.

12. Follow-up Repeat Triple phase Abd CT: Lateral segment of liver was enlarged with a nodular contour. Right lobe was atrophic. Liver morphology consistent with cirrhosis. Repeat Liver biopsy: Moderate micro and macrosteatosis with moderate portal and lobular inflammation. Fibrous septa was present consistent with transition to cirrhosis (Grade 2).

13. Follow-up The patient subsequently had a positive glucose tolerance test and was started on Pioglitazone. A 6 month follow-up hepatic function panel revealed normalization of the transaminase levels

14. Final Diagnosis Nonalcoholic steatohepatitis leading to cirrhosis.