2476 Fibrinogen-Positive Ground Glass Hepatocytes in a Patient With Ulcerative Colitis

Abstract

INTRODUCTION: Ground-glass hepatocyte cytoplasmic inclusions (eosinophilic, glassy cytoplasmic changes) carry a unique differential diagnosis with significant diagnostic implications. This cytoplasmic change is thought to occur from accumulation of metabolic products including glycogen, fibrinogen, or viral proteins. Few cases of patients with ground-glass, fibrinogen-positive inclusions have been observed and are thought to occur from acute states of metabolic stress. CASE DESCRIPTION/METHODS: A 64-year-old male with history of poorly controlled ulcerative colitis presented with diffuse abdominal pain, weight loss, and two months of frequent bloody bowel movements. On arrival, he was afebrile without abnormal vital signs. His appearance was non-toxic but malnourished. Abdominal exam produced diffuse tenderness but no evidence of peritonitis. Labs were notable for AST 233 U/L, ALT 486 U/L, and Alk phos 140 U/L (normal 56-119 U/L). He failed trial of medical therapy and required total abdominal colectomy. His aminotransferase levels during this time continued to worsen without explanation (peak AST 710 U/L and ALT 1145 U/L). Serum infectious disease workup including Hepatitis C antibody, HIV Antibody/Antigen screen, Hepatitis B core antibody and surface antigen, Hepatitis E IgM antibody, HSV-1 and 2 PCR, and Varicella-zoster PCR were all negative. Serum IgG, IgA, TTG-IgA, anti-smooth muscle antibody and anti-nuclear antibody testing were unremarkable. Abdominal ultrasound with doppler showed patency of the portal, splenic, and hepatic veins without thrombus. Liver biopsy showed moderately active steatohepatitis, and hepatocytes displayed ground-glass cytoplasmic appearance. PAS staining showed weak to no staining of ground-glass regions. Due to the lack of positive PAS staining, fibrinogen staining of the liver specimen was obtained, which showed diffuse positivity within hepatocytes. DISCUSSION: A rarely reported finding, fibrinogen accumulation in hepatocytes can occur from inherited disease and from acquired errors in endoplasmic reticulum processing in a setting of metabolic stress. Ground glass hepatocyte inclusions staining positive with fibrinogen have only been associated with the acquired causes in humans. Only 3 cases, to our knowledge, have shown similar findings. After 1 year follow-up from total colectomy, his aminotransferases had returned to normal range.