case_images: PMC10965232_01
case_images: a-d Liver biopsies demonstrating bridging fibrosis and periportal and lobular lymphoplasmacytic inflammation (x10 magnification). a Initial liver biopsy showing periportal lymphoplasmacytic inflammation (arrow; H&E stain). b Initial liver biopsy with bridging fibrosis highlighted in blue (grade 3-4, arrow, trichrome stain). c Repeat liver biopsy, showing periportal (arrow) and lobular (star) lymphoplasmacytic inflammation (H&E stain). d Repeat liver biopsy showing bridging fibrosis highlighted in blue (grade 3-4, arrow, trichrome stain).
case_images: crg-2024-0018-0001-537798_F01.jpg
case_images: PMC10965232_01_crg-2024-0018-0001-537798_F01.jpg
case_images: F1
case_images: AIH (shown in Fig. 1). At the time of her presentation to the emergency department, liver transplant evaluation was pending.
case_images: MRCP showing beading and irregularity of the intrahepatic biliary tree and cystic duct, in keeping with known history of PSC. This image also highlights the dilation of the intrahepatic and extrahepatic biliary system.
case_images: crg-2024-0018-0001-537798_F02.jpg
case_images: PMC10965232_01_crg-2024-0018-0001-537798_F02.jpg
case_images: F2
case_images: She underwent magnetic resonance cholangiopancreatography (MRCP) which was significant for cirrhotic liver morphology with nodular surface contour and intrahepatic and extrahepatic biliary dilatation with beading and irregularity of the intrahepatic biliary tree and cystic duct, consistent with PSC (shown in Fig. 2).
case_images: a-c Lab values over time: fecal calprotectin (a), aspartate transferase (AST) (b), alanine transaminase (ALT) (c). Legend: (1) started on prednisone while in the hospital, and 12 days later, started on ustekinumab injections + azathioprine; (2) started on vancomycin given no symptomatic improvement with the previous medications; (3) patient self-discontinued vancomycin without telling provider; (4) patient made appointment with provider as she was not feeling well; was restarted on vancomycin.
case_images: crg-2024-0018-0001-537798_F03.jpg
case_images: PMC10965232_01_crg-2024-0018-0001-537798_F03.jpg
case_images: F3
case_images: Although she had partial symptomatic improvement from her UC flare, it was not until 3 weeks after the subsequent addition of vancomycin that she achieved normalization of her biochemical markers (liver enzymes, fecal calprotectin) (shown in Fig. 3), endoscopic improvement of her UC, and full clinical remission.