case_images: PMC10075219_01
case_images: Photomicrographs of the liver biopsy. A - acute/subacute pattern of injury: there is a lymphocyte-predominant portal and lobular inflammation with spotty hepatocellular necrosis without significant ductal aggression (H&E, 10x); B - the "cholestatic hepatitis" injury with spotty necrosis, and acidophil bodies (H&E, 20x).
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case_images: In the lack of a specific diagnosis, a real-time ultrasound-guided percutaneous liver biopsy was performed, and the histologic evaluation showed acute/subacute hepatitis, with numerous foci of lobular necrosis, associated with moderate canalicular and intrahepatocytic cholestasis, predominantly in zone 3, without ductopenia or portal biliary reaction (Figures 1A and 1B).
case_images: Laboratory tests over time. ALP: alkaline phosphatase; ALT: alanine aminotransferase; AST: aspartate aminotransferase; AZA: azathioprine; GGT: gamma-glutamyl transferase; TB: total bilirubin; UDCA: ursodeoxycholic acid.
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case_images: The biochemical response was suboptimal (Figure 2), and a second liver biopsy was then performed two months later. The evolution of liver tests according to the treatment is displayed in Figure 2.
case_images: Photomicrograph of the second liver biopsy. A - extensive aggression of the bile duct, with cytoplasmic vacuolization, pyknotic nuclei and a plasma-cell rich infiltrate (H&E, 20x); B - there is a chronic destructive aggression of the bile duct, with numerous plasma cells and interface activity; C - portal and lobular granulomas are also present (H&E, 10x); D - confluent necrosis and pseudorosette hepatocellular regeneration (H&E, 20x).
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case_images: gf03