Multifocal Nodular Non-Alcoholic Steatohepatitis (NASH)

Abstract

Introduction: Insulin sensitizers have been reported to improve liver biochemistry and histology in patients with NASH. Rarely fatty lesions in liver can be multifocal and nodular, and mimic metastatic disease to the liver. We describe a patient with multifocal nodular NASH who's radiological and biochemical abnormalities resolved with rosiglitazone. Case: A 59-year-old white female with metabolic syndrome underwent CT scan of her liver to evaluate abnormal transaminases. This revealed a hypodense mass with a size of 10.5 cm in maximum diameter in left lobe with multifocal nodular lesions in the right lobe of liver. This was initially concerning for malignant disease. However MRI suggested multifocal nodular fatty liver. A laparoscopic liver biopsy was nevertheless elected. The liver surface had yellowish discoloration with fibrotic changes. Biopsy showed changes consistent with NASH and early fibrosis. The patient was started on vitamin E 400 IU daily. At 6 months there was no change in CT scan findings. Rosiglitazone 4 mg twice a day was added and vitamin E was continued. Six months later her hemoglobin A1C improved from 6.7% to 6.1%. Her fasting glucose and insulin levels improved. She was able to improve her body mass index from 29.3 to 26.6. Transaminases normalized. A repeat CT scan done after 6 months of rosiglitazone showed resolution of multifocal nodular fatty liver lesions. Conclusion: This case illustrates that multifocal nodular fatty liver can mimic metastatic disease to the liver. Rosiglitazone resulted in improvement in insulin resistance and dramatic resolution of nodular fatty lesions on CT scan.