Abnormal Liver Function Tests in the Third Trimester: A Diagnostic Dilemma

Abstract

Question: A 35-year-old gravida 4, para 1 at 32 weeks with recent cocaine ingestion presented with nausea and vomiting. Initial vital signs were normal with blood pressure 110/65 mmHg and heart rate 75 beats per minute. Physical examination revealed a gravid abdomen with tenderness in the right upper quadrant but no rebound or guarding. She had no evidence of encephalopathy. Laboratory studies revealed elevated liver function tests (LFTs) with a peak alanine aminotransferase level of 507 IU/L, renal failure with a creatinine level of 3.9 mg/dL, leukocytosis, and hypoalbuminemia to 2.3 g/dL. She had a normal anion gap without evidence of acidosis. Her platelet count and prothrombin time were also normal. Urinalysis showed no evidence of proteinuria. The patient had no prior history of liver disease. Her hepatitis A, B, and C serologies as well as an HIV test were negative. She had normal complement levels and negative antinuclear and antismooth muscle antibodies. An abdominal ultrasound showed nonspecific echogenic portal triads and an echocardiogram was normal. Her alanine aminotransferase and creatinine levels both improved over a 24-hour period to 330 IU/L and 2.6 mg/dL, respectively. A liver biopsy was performed. A frozen section with special staining is seen in Figure A. Hematoxylin and eosin tissue stains are also shown in low (Figure B) and high (Figure C) power. What is the diagnosis? Look on page 1136 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.