Medical College of Georgia at Augusta University Augusta, GA
Muaaz Masood, MD1, Dariush Shahsavari, MD2 1Medical College of Georgia at Augusta University, Augusta, GA; 2Medical College of Georgia - Augusta University, Augusta, GA
Introduction: Hepatic granulomas are found in 2-10% of liver biopsies. Granulomatous hepatitis (GH) has numerous etiologies and is often associated with an underlying systemic disease. We present a case of GH after extensive testing for liver disease returned normal.
Case Description/Methods: A 53-year-old Caucasian female with a history of obesity presented with 4 days of right upper quadrant (RUQ) abdominal pain, jaundice, nausea, pale stools and dark urine. She was raised on a farm with animals. Her mother died of an unknown liver disease. Liver enzyme tests revealed AST 258 U/L, ALT 236 U/L, alk phos 631 U/L, T. bili 5.5 mg/dL and D. bili 3.2 mg/dL. Comprehensive testing for liver disease was unremarkable. CT scan revealed hepatomegaly and magnetic resonance cholangiopancreatography showed hepatomegaly with diffuse hepatic steatosis. Atorvastatin was discontinued. Patient had improvement in her liver enzymes. She was discharged home after 6 days and scheduled for an outpatient liver biopsy. She returned to the hospital 5 days later with similar symptoms, persistently elevated alk phos and an increase in Tbili to 8.5 mg/dL (DBili 5.5 mg/dL). She underwent endoscopic ultrasound-guided liver biopsy which revealed granulomatous hepatitis. A thorough investigation was performed to assess the underlying cause. The patient was discharged home in stable condition while awaiting results of reference labs.
Discussion: Granulomatous hepatitis (GH) has many causes including infectious (i.e. bacterial, fungal, viral, parasitic), autoimmune (i.e. primary biliary cholangitis [PBC]), drug-induced (i.e. sulfonylureas, allopurinol), metals (i.e. beryllium, copper, gold), extrahepatic malignancy or idiopathic. Sarcoidosis, mycobacterial infection, PBC and drug-induced GH represent the most common etiologies. GH may be asymptomatic, can present with hepatobiliary symptoms or with constitutional symptoms from systemic disease. Imaging may be normal or reveal hepatomegaly as in our case. Liver biopsy is the best diagnostic tool for GH. Symptomatic and idiopathic GH often responds to corticosteroids once infection has been excluded. Methotrexate or infliximab have also been used. Offending agents should be discontinued. It is speculated that our case may have been due to exposure to a zoonotic infection. Complications of GH include fibrosis, portal hypertension and cirrhosis. GH should be considered in a patient with RUQ abdominal pain, fever, hepatomegaly and elevated LFTs in the appropriate clinical context.
Disclosures:
Muaaz Masood indicated no relevant financial relationships.
Dariush Shahsavari indicated no relevant financial relationships.
Muaaz Masood, MD1, Dariush Shahsavari, MD2. E0547 - Granulomatous Hepatitis: The Search for a Culprit, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.
