case_images: PMC11813197_01
case_images: MRI of the liver. A: T1 weighted; B, T2: weighted; A/B: Liver with slight heterogeneity of parenchymal texture, related to suspicion of hepatitis. Multiple liver hilar lymphadenopathy, with short axes that do not exceed 7 mm. Splenomegaly, measuring the spleen 174 mm in the greatest axis. No other relevant changes.. MRI, magnetic resonance imaging
case_images: cureus-0017-00000077331-i01.jpg
case_images: PMC11813197_01_cureus-0017-00000077331-i01.jpg
case_images: FIG1
case_images: Abdominal ultrasound and magnetic resonance imaging (MRI) ruled out liver disease progression (Figure 1).
case_images: Longitudinal levels of serum ALT, AST, GGT, ALP, and bilirubin during hospitalization. ALP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; Bil, bilirubin; GGT, gamma-glutamyl transferase; CS, corticosteroid; MMF, mycophenolate mofetil
case_images: cureus-0017-00000077331-i02.jpg
case_images: PMC11813197_01_cureus-0017-00000077331-i02.jpg
case_images: FIG2
case_images: One week after admission, we observed a paradoxical biochemical response: an improvement in AST and ALT to grade 3 but a progressive worsening of hyperbilirubinemia and GGT to grade 4 (Figure 2). One week after introducing MMF and considering liver parameters improvement, we started tapering down CS (Figure 2).
case_images: Percutaneous liver biopsy. A: Trabecular collapse and moderate-to-marked inflammatory infiltrate in both periportal and centrilobular regions (HE, 4x). B: Interface hepatitis (HE, 10x). C: Hepatocyte degeneration, including multinucleated cells (green arrow; HE, 40x). D: Acidophilic bodies (blue arrow) and signs of hepatocanalicular cholestasis (circle) (HE, 40x). E: Bile ducts exhibited cytoplasmic vacuolation, nuclear overlap, and irregular nuclear contours, consistent with bile duct injury (HE, 40x). F: Cytokeratin 7 highlighted hepatocytes with intermediate phenotype (cytokeratin 7 immunostain, 20x).
case_images: cureus-0017-00000077331-i03.jpg
case_images: PMC11813197_01_cureus-0017-00000077331-i03.jpg
case_images: FIG3
case_images: Masson's trichrome stain demonstrated mild periportal and "chicken-wire" centrilobular fibrosis (Figure 3).
case_images: Longitudinal levels of serum ALT, AST, GGT, ALP, and bilirubin during the second hospitalization and respective evolution after discharge. ALP, alkaline phosphatase; ALT, alanine aminotransferase; AST, aspartate aminotransferase; Bil, bilirubin; GGT, gamma-glutamyl transferase; UDCA, ursodeoxycholic acid
case_images: cureus-0017-00000077331-i04.jpg
case_images: PMC11813197_01_cureus-0017-00000077331-i04.jpg
case_images: FIG4
case_images: One week after discharge, the patient was readmitted due to a hepatitis relapse, evidenced by grade 4 elevations in AST and ALT (922 U/L and 1053 U/L, respectively), grade 3 hyperbilirubinemia (total and direct bilirubin levels of 8.54 and 5.04 mg/dL), and GGT (958 U/L) (Figure 4). The patient was managed with intravenous methylprednisolone at 1.5 mg/kg/day, resulting in improvement of liver function tests to grade 1 level (AST: 41 U/L, ALT: 54 U/L, total and direct bilirubin: 2.34 and 0.96 mg/dL, ALP: 200 U/L), except for GGT, which remained elevated at grade 3 (522 U/L) (Figure 4). ALT to grade 3 (225 U/L and 397 U/L, respectively), grade 3 hyperbilirubinemia (total and direct bilirubin of 3.27 and 1.62 mg/dL) and grade 4 GGT elevation (1883 U/L) (Figure 4). As a result, UDCA 750 mg (13 mg/kg/day) once daily was initiated. After four weeks of treatment, AST, and ALT normalized (AST: 40 U/L and ALT: 35 U/L), and hyperbilirubinemia decreased to grade 1 (total and direct bilirubin: 1.46 mg/dL and 0.61 mg/dL, respectively). Still, GGT only improved for a grade 3 elevation (919 U/L) (Figure 4).
case_images: Comparative images from computed tomography scans performed at treatment baseline (A) and three months after treatment discontinuation (B), evidencing disease progression according to the RECIST criteria . A: target lesion measuring 67 mm; B: target lesion measuring 80 mm + new lesions on lymph nodes and a new onset pleural effusion.
case_images: cureus-0017-00000077331-i05.jpg
case_images: PMC11813197_01_cureus-0017-00000077331-i05.jpg
case_images: FIG5
case_images: Regarding treatment outcomes, the disease has progressed three months after treatment discontinuation (Figure 5).