Khat it out! A Nodular Regenerative Hyperplasia Case

Abstract

Nodular regenerative hyperplasia (NRH), is a rare liver disease marked by diffuse transformation of normal hepatic parenchyma into small, regenerative nodules with little to no fibrosis, which can lead to portal hypertension. Incidence varies and is associated with chronic or recurrent infection, exposure to drugs or toxins, hypercoagulability, immunologic disorders or genetic disorders. The use of khat has never been reported as a potential cause of NRH, but it is a known cause of acute hepatitis and cirrhosis. We report a case of a young women who developed NRH in the setting of prior khat use. A 31 year old woman from Yemen presented with worsening abdominal pain and jaundice over several months. She denied alcohol use, but reported a remote history of khat use 7 years ago. On initial evaluation, her vitals were normal and physical exam was significant for scleral icterus, abdominal ascites, and palpable hepatosplenomegaly. Laboratory testing revealed severe pancytopenia and liver tests significant for ALP/ALT/AST of 214/112/116, respectively. Coagulation studies were normal. MRI of the abdomen showed patent portal veins, portal hypertension with marked splenomegaly, and extensive periesophageal, perisplenic, perigastric and abdominal varices. A comprehensive infectious, autoimmune and anticoagulation workup was done and unremarkable. On upper endoscopy, small varices were found in the distal esophagus without stigmata of bleeding, as well as moderate portal hypertensive gastropathy (PHG) in the gastric fundus and body. A liver biopsy revealed regenerative hepatocyte plate architecture and patchy sinusoidal dilatation, consistent with nodular regenerative hyperplasia (Image 2). She was treated with carvedilol for anemia secondary to PHG. NRH is a diagnosis of exclusion with liver biopsy being the gold standard for diagnosis. Clinical evidence of portal hypertension without evidence of cirrhosis is key when including NRH in the differential diagnosis. Khat use has been reported to cause acute liver injury and when severe, may cause fibrosis and cirrhosis. Upon literature review, khat has not been shown to be associated with NRH. Thorough history taking and exclusion of more common causes of liver disease i.e. infectious hepatitis and alcoholic or non-alcoholic fatty liver disease, are crucial prior to considering NRH.Figure: MRI Abdomen showing hepatosplenomegaly and nodular shrunken liver with hepatic fibrosis and portal venous distension.Figure: Small (< 5 mm) varices (arrows) noted in the lower third of the esophagus on upper endoscopy.Figure: Liver biopsy showing reduced reticulin fibers and expanded hepatocyte cell plates in an area of regeneration (reticulin stain).