Mallory Bodies Research Articles

Diethyldithiocarbamate, an anti-abuse drug, alleviates steatohepatitis and fibrosis in rodents through modulating lipid metabolism and oxidative stress.

Diethyldithiocarbamate (DDC) is a major metabolite of disulfiram that is a potential drug for alcoholism treatment. In the present study, we attempted to explore the possible effect of DDC on non-alcoholic fatty liver disease (NAFLD) and related fibrosis in vivo. C57BL/6 mice and Sprague Dawley (SD) rats received a methionine/choline-deficient (MCD) diet to establish the model of NAFLD with or without DDC treatment. The livers and serum were assessed for histological changes and parameters related to lipid metabolism, liver injury, inflammation and fibrosis. Apoptosis and macrophage related markers were assessed by immunohistochemistry (IHC). DDC significantly reduced hepatic steatosis in rats with NAFLD, induced by the MCD diet. DDC reduced the oxidative stress and endoplasmic reticulum stress-related parameters in mice with non-alcoholic steatohepatitis, induced by the MCD diet. IHC for Bax and cleaved caspase-3 showed that DDC inhibited the apoptosis of hepatocytes in the liver. DDC significantly reduced ballooning and Mallory-Denk bodies (MDB) in hepatocytes, accompanied by suppression of serum alanine aminotransferase, aspartate aminotransferase and MDB formation-related genes. DDC significantly alleviated hepatic inflammation, accompanied by suppression of inflammation-related genes. DDC suppressed the infiltration of macrophages, particularly inducible NOS-positive pro-inflammatory macrophages. In addition, DDC significantly alleviated liver fibrosis. Microarray analyses showed that DDC strongly affected lipid metabolism and oxidative stress-related processes and pathways. DDC improves hepatic steatosis, ballooning, inflammation and fibrosis in rodent models of NAFLD through modulating lipid metabolism and oxidative stress.

Spirochetes in the Liver: An Unusual Presentation of a Common Infection

A 67-year-old male was admitted for progressive liver enzyme elevation. His symptoms began three months prior to this admission, when he presented to the ED with fatigue, decreased appetite, and abdominal pain, and was found to have elevated transaminases. Initial workup by his outpatient gastroenterologist was inconclusive. Subsequently, he developed weakness and numbness that began distal to his axillae and progressed to his torso and lower extremities. On presentation, he attested to anorexia, 18lb weight loss, weakness. He also identified a non-itchy painless rash that began ten days prior on his arms and then spread to his torso, palms and thighs. He denied use of alcohol, tobacco or drugs. He admitted to being sexually active with 5-10 male partners in the past year. No recent travel or sick contacts. No use of antibiotics or herbal supplements. On physical examination, he had scleral icterus, bilateral pitting lower extremity edema. His skin had a non-tender maculopapular rash, most notable on the palms, thighs, chest, and scalp. Admitting labs were significant for total bilirubin 5.9, AST 201, ALT 116, alkaline phosphatase 1048. Abdominal CT scan showed hepatomegaly with heterogeneous attenuation, patent hepatic vasculature, no focal lesions, and mild splenomegaly. MRCP showed no extrahepatic biliary obstruction. Liver biopsy was performed. The coexistence of dermatologic, neurologic and hepatic signs and symptoms prompted evaluation for syphilis. The patient had a reactive RPR titer of 1:256, reactive TPPA and syphilis total antibody ratio of 15.8. Additionally, HIV screening was positive with a viral load of 650,493 copies/mL and CD4+ count of 946 cells/mm3. Liver pathology showed macrovesicular and microvesicular steatosis with focal hepatocellular ballooning and Mallory-Denk bodies, patchy PAS-D positive cytoplasmic hyaline globules, and periportal and sinusoidal fibrosis (image 1). Diagnosis of syphilitic hepatitis was confirmed by immunostain showing numerous treponemal spirochetes (Image 2). He was started on Penicillin G, and his liver enzymes improved impressively (Table 2). A lumbar puncture was performed and showed cell count of 7, non-reactive CSF titer, protein of 55mg/dL, and glucose of 85 mg/dL, thus ruling out neurosyphilis. Thus, it is important that early identification of this infrequent presentation of syphilis is made because of its easy reversibility and subsequent prevention of progression to further stages.2230_A Figure 1 No Caption available.2230_B Figure 2 No Caption available.

An Atypical Presentation of Alcoholic Hepatitis

Significant alcohol consumption leads to a variety of alcoholic liver diseases ranging from alcoholic fatty liver disease to alcoholic cirrhosis. Alcoholic hepatitis carries a high risk of mortality; therefore, it is important to identify patients early to guide treatment and management. We discuss an atypical presentation of alcoholic hepatitis, with initial concern for lymphoproliferative disease. Our patient was a 28—year—old Cantonese—American man presenting with one month of abdominal pain, fevers, night sweats, and weight loss. His social history was not impressive for chronic alcohol use;he was a social drinker who drank 1 beer and 3 whisky shots every 4 months. Physical exam revealed tachycardia, abdominal tenderness, hepatosplenomegaly, and diffuse jaundice with no stigmata of chronic liver disease. Labs revealed leukocytosis with white blood cell count of 22x103/uL, conjugated hyperbilirubinemia (total bilirubin:4.4mg/dL), elevated alkaline phosphatase(183 U/L), and an INR of 1.43. An infectious process was ruled out when cultures and CXR were unrevealing. An abdominal ultrasound revealed hepatomegaly and ascites, but no ductal dilatation,which was confirmed on MRCP. Given his age, presence of B symptoms, and lack of significant alcohol history, there was concern for underlying malignancy. A CT abdomen showed abdominal lymphadenopathy and hepatosplenomegaly with a subsequent PET—CT scan showing diffuse lymphadenopathy and increased bone marrow activity. Hematology performed a bone marrow biopsy that revealed no signs of a neoplastic process. Patient's bilirubin continued to rise to 20mg/dL so a transjugular liver biopsy was obtained. Measurements revealed portal hypertension with HVPG of 10 and histology demonstrated steatosis, mild portal fibrosis,and Mallory body formation with neutrophilic infiltrates, suggestive of alcoholic hepatitis. The patient's Maddrey Discriminant Function score was elevated at 34 and he was started on prednisolone. At day 7 his Lille score was 0.04, indicating response to steroids. He completed a 28—day course of prednisolone and had complete resolution of fevers, ascites and biochemical abnormalities, while remaining abstinent. This is a case of alcoholic hepatitis presenting atypically with B symptoms, lack of strong drinking history, and diffuse lymphadenopathy, all suggestive of lymphoma. This case highlights the importance of pursuing a liver biopsy early on to confirm a diagnosis of alcoholic hepatitis.

Histopathologic Approach to Cholestatic Diseases of the Liver

Abstract Liver biopsy specimens of patients with cholestatic diseases pose a challenge to pathologists since, in most instances, this procedure is performed in a selected group of patients in whom clinical, laboratory, and imaging studies are inconclusive. Proper interpretation of the various histologic features is facilitated by the recognition of the most common patterns, which correlate with a defined group of diseases. Cholestatic disorders are grouped in 2 broad categories: acute and chronic. Four histologic patterns with different clinical implication are recognized within the first category: (1) ductular reaction, (2) pure canalicular cholestasis, (3) cholestasis with intrahepatic bile duct disease, and (4) cholestatic hepatitis. Chronic disorders are recognized by portal-based fibrosis, Mallory-Denk bodies, cholate stasis, accumulation of copper or copper-binding proteins, and biliary-type cirrhosis. Immunohistochemical reactions for cytokeratin 7 help to identify damaged bile ducts, highlight reactive ductules, and, most importantly, provide support for a cholestatic disorder by the staining of periportal hepatocytes (intermediate phenotype). The histologic features of primary biliary cholangitis and primary sclerosing cholangitis are reviewed with special emphasis on overlap syndromes and other entities that enter in the differential diagnosis.

The PPAR\u03b1 Agonist Fenofibrate Prevents Formation of Protein Aggregates (Mallory-Denk bodies) in a Murine Model of Steatohepatitis-like Hepatotoxicity

Chronic intoxication of mice with the porphyrinogenic compound 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC) leads to morphological and metabolic changes closely resembling steatohepatitis, a severe form of metabolic liver disease in humans. Since human steatohepatitis (both the alcoholic and non-alcoholic type) is characterized by reduced expression of PPARα and disturbed lipid metabolism we investigated the role of this ligand-activated receptor in the development of DDC-induced liver injury. Acute DDC-intoxication was accompanied by early significant downregulation of Pparα mRNA expression along with PPARα-controlled stress-response and lipid metabolism genes that persisted in the chronic stage. Administration of the specific PPARα agonist fenofibrate together with DDC prevented the downregulation of PPARα-associated genes and also improved the stress response of Nrf2-dependent redox-regulating genes. Moreover, oxidative stress and inflammation were strongly reduced by DDC/fenofibrate co-treatment. In addition, fenofibrate prevented the disruption of hepatocyte intermediate filament cytoskeleton and the formation of Mallory-Denk bodies at late stages of DDC intoxication. Our findings show that, like in human steatohepatitis, PPARα is downregulated in the DDC model of steatohepatitis-like hepatocellular damage. Its downregulation and the pathomorphologic features of steatohepatitis are prevented by co-administration of fenofibrate.

Increased hepatic FAT/CD36, PTP1B and decreased HNF4A expression contributes to dyslipidemia associated with ethanol–induced liver dysfunction: Rescue effect of ginger extract

The association between chronic alcohol consumption and the development of alcpholic liver disease is a very well known phenomenon, but the precise underlying molecular mediators involved in ethanol-induced liver disease remain elusive. This study aimed to characterize the lipid metabolism alterations and the molecular mediators which are related to lipid metabolism in liver under the heavy ethanol exposure alone or combined with ginger extract. Twenty-four male wistar rats were assigned into three groups, namely control, ethanol, and ginger extract treated ethanol (GETE) groups. Six weeks after the treatment, the ethanol group showed a significant increase in fatty acid translocase (FAT)/CD36, protein tyrosine phosphatase 1B (PTP1B) and decrease hepatocyte nuclear factor 4 Alpha (HNF4A) genes expressions compared to the control group. The ethanol administration also significantly increased plasma LDL, cholesterol, triglyceride, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) compared to the control group. Moreover, compared to the control group, the ethanol group showed liver histhological changes, such as fibrosis, focal microvesicular steatosis, some apoptotic hepatocytes, spotty necrosis, portal lymphocytic inflammation, mallory-denk bodies, giant mitochondria, piecemeal necrosis. Consumption of ginger extract along with ethanol, partially ameliorated gene expression alteration and histological changes, improved undesirable lipid profile and liver enzymes changes compare to those in the ethanol group. These findings indicate that ethanol-induced liver abnormalities may in part be associated with lipid homeostasis changes mediated by overexpression of FAT/CD36, PTP1B and downexpressionof HNF4A genes. It also show that these effects can be reduced by using ginger extract as an antioxidant and anti-inflammatory agent.

Highlights from the Diabetes UK Professional Conference 2018

Highlights from the Diabetes UK Professional Conference 2018

ОСОБЛИВОСТІ УЛЬТРАСТРУКТУРИ ОСЕРЕДКІВ РЕНАЛЬНОЇ ІНТРАТУБУЛЯРНОЇ НЕОПЛАЗІЇ ПРИ СВІТЛОКЛІТИННОМУ РАКУ НИРКИ

The aim was to investigate in a comparative plan the ultrastructural peculiarities of cells, cellular and noncellular elements of renal intratubular neoplasia of peritumoral tissue with highly, average and low grades of differentiation at clear cell renal cell carcinoma (CCRCC). Material and methods. Material for conducting transmission electron microscopic researches was postoperative biopsies of the peritumoral tissue at highly differentiated CCRCC (G1) – five cases; at an average grade of differentiation (G2) – five cases; at low grade of differentiation (G3) – six cases. The renal tubules (RT) and tangential stroma elements with different differentiation (G1, G2, G3) in peritumoral tissue at the ultrastructural level were investigated. Results. It was revealed that in RT of peritumoral tissue at highly differentiated CCRCC (G1) and the average degree of differentiation (G2) cells of renal intratubular neoplasia zones are represented mainly in the average electronic density by little-differentiated epithelial cells with a large nuclear-cytoplasmic ration. Epithelial cells with small nuclear-cytoplasmic ratio, the cytoplasm of which is filled with disorganized small mitochondria, Mallory bodies, glycogen granules and autophagosomes, are present in separate cells zones of the renal intratubular neoplasia with the CCRCC of the indicated degrees of differentiation. Peritumoral tissue at highly differentiated CCRCC (G1) and the average degree of differentiation (G2) contains hemocapillaries, small venules, clusters of fibroblasts, macrophages, plasmocytes. A characteristic ultrastructural feature of peritumoral tissue with a low degree of differentiation (G3) at CCRCC is the presence of a small diameter RT coated with very thick and simultaneously flaky basal membranes. Typical for separate small differentiated epithelial cells of renal intratubular neoplasia zones RT of peritumoral tissue at CCRCC of low degree of differentiation (G3) is the presence in their cytoplasm of a very large size, spherical form of Mallory body with the electron-density, connected with the outer membrane of the nuclear shell. It was also revealed that in the conditions of renal intratubular neoplasia, a number of zones of renal intratubular neoplasia RT of peritumoral tissue are filled with epithelial cells, the cytoplasm of which contains a giant size of the autophagosome and electron-density cluster of glycogen granules. The autophagosome contains small lipid drops of insignificant electron density and approximately the same size of a very high electron density spherical formation of unspecified nature. Conclusions. Epithelial cells of the renal intratubular neoplasia zones of peritumoral tissue at CCRCC of low degree of differentiation (G3), in the comparative plan with similar epithelial cells of the renal intratubular neoplasia zones of peritumoral tissue with high (G1) and the average (G2) degrees of differentiation, have cytoplasm, which is the most saturated Mallory bodies, autophagosomes, electron-density clusters of granules of glycogen.

Hsp72 protects against liver injury via attenuation of hepatocellular death, oxidative stress, and JNK signaling

Heat shock protein (Hsp) 72 is a molecular chaperone that has broad cytoprotective functions and is upregulated in response to stress. To determine its hepatic functions, we studied its expression in human liver disorders and its biological significance in newly generated transgenic animals. Double transgenic mice overexpressing Hsp72 (gene Hspa1a) under the control of a tissue-specific tetracycline-inducible system (Hsp72-LAP mice) were produced. Acute liver injury was induced by a single injection of acetaminophen (APAP). Feeding with either a methionine choline-deficient (MCD; 8 weeks) or a 3,5-diethoxycarbonyl-1,4-dihydrocollidine-supplemented diet (DDC; 12 weeks) was used to induce lipotoxic injury and Mallory-Denk body (MDB) formation, respectively. Primary hepatocytes were treated with palmitic acid. Patients with non-alcoholic steatohepatitis and chronic hepatitis C infection displayed elevated HSP72 levels. These levels increased with the extent of hepatic inflammation and HSP72 expression was induced after treatment with either interleukin (IL)-1β or IL-6. Hsp72-LAP mice exhibited robust, hepatocyte-specific Hsp72 overexpression. Primary hepatocytes from these animals were more resistant to isolation-induced stress and Hsp72-LAP mice displayed lower levels of hepatic injury in vivo. Mice overexpressing Hsp72 had fewer APAP protein adducts and were protected from oxidative stress and APAP-/MCD-induced cell death. Hsp72-LAP mice and/or hepatocytes displayed significantly attenuated Jnk activation. Overexpression of Hsp72 did not affect steatosis or the extent of MDB formation. Our results demonstrate that HSP72 induction occurs in human liver disease, thus, HSP72 represents an attractive therapeutic target owing to its broad hepatoprotective functions. HSP72 constitutes a stress-inducible, protective protein. Our data demonstrate that it is upregulated in patients with chronic hepatitis C and non-alcoholic steatohepatitis. Moreover, Hsp72-overexpressing mice are protected from various forms of liver stress.

Pathomorphological analysis of nonalcohoholic and alcoholic steathohepatitis adverse consequences

Background. Non-alcoholic steatohepatitis (NASH) and alcoholic steatohepatitis (ASH) are widespread in all countries, they are complicated by cirrhosis and liver cancer, which cause death to 4% of the world's population.The early diagnosis of these diseases in trepanobioptates of the liver and the prediction of their course is of particular importance. Objective. pathomorphological analysis of activation and complications of NASH and ASH manifestations in biopsy section material. Methods. 185 histopathological and histochemical and immunohistochemical studies of NASH, ASH, cirrhosis and liver cancer were performed in 185 liver trepanobioptates and in the sectional material of 451 patients. Results. The following pathomorphological signs of activation of NASH and ASH are revealed: transient growth of hepatocyte steatosis, increased inflammation-cell infiltration of hepatic lobules, an increase in the number of hepatocytes with Mallory-Denk bodies and neutrophilic-cellular satellitosis, an increase in the incidence of necroptosis, apoptosis and balonization (balloon lysis) of hepatocytes, and infrequent signs: the increase in immunocellular killing, autophagy in hepatocytes and the deposition of iron in the liver. The indicator of severity and duration of NASH and ASH is perisinusoidal pericellular and portal-Z3perisinusoidal hepatic fibrosis, progressing from a mild F1 degree, through an average F2 degree to severe F3 fibrosis. Conclusion. Adverse complications of NASH and ASH is micronodular cirrhosis of the perisinusoidal pericellular or portal-Z3perisinusoidal type, as well as rarely developing hepatocellular liver cancer.

Prediction of histologic alcoholic hepatitis based on clinical presentation limits the need for liver biopsy.

The clinical presentation of alcoholic hepatitis (AH) can be mimicked by other alcoholic liver diseases. The aim of this study was to identify clinical features that predict AH on liver biopsy. Biopsies from patients hospitalized for presumed severe AH were used to identify a derivation cohort (101 patients) and validation cohort (71 patients). Using histologic scores for hepatocyte ballooning, Mallory‐Denk bodies, and lobular inflammation, 95 patient biopsies (55%) were classified as definite AH, 55 (32%) as possible AH, and 22 (13%) as no AH. Survival was similar among the groups, but mortality was significantly increased for patients with fatty change ≤50% on initial liver biopsy. An analysis limited to uninfected patients with definite AH or no AH in the derivation cohort identified a greater leukocyte count at admission and radiographic evidence of liver surface nodularity as independent predictors of definite AH on biopsy (P < 0.05). In the derivation cohort, the leukocyte count thresholds for ensuring 100% specificity for diagnosing definite AH were 10 × 109/L if the liver surface was nodular and 14 × 109/L if the liver surface was smooth, with a sensitivity of 76% and an area under the receiver operator characteristic curve of 0.88. In the validation cohort, these thresholds had a specificity of 86%, a sensitivity of 59%, and an area under the receiver operator characteristic curve of 0.72. Conclusion: The combination of an elevated leukocyte count and a nodular liver surface in the absence of active infection retrospectively identified patients with a high likelihood of histologic AH for whom liver biopsy may not be necessary. For patients with suspected severe AH who do not fulfill these criteria, liver biopsy is important to exclude other variants of alcoholic liver disease. (Hepatology Communications 2017;1:1070–1084)

Novel non-alcoholic steatohepatitis model with histopathological and insulin-resistant features.

Although several non-alcoholic steatohepatitis (NASH) models have been reported to date, few of these models fully reflect the histopathology and pathophysiology of human NASH. The aim of this study was to establish a novel NASH model by feeding a high-fat (HF) diet and administering both carbon tetrachloride (CCl4 ) and the Liver X receptor agonist T0901317. Male C57BL/6J mice were divided into four groups (each n = 5): HF, HF + CCl4 , HF + T0901317, and the novel NASH model (HF + CCl4 + T0901317). CCl4 (0.1 mL/kg) and T0901317 (2.5 mg/kg) were intraperitoneally administered four times and five times, respectively. The livers of the novel NASH model group presented a whitish colour. The serum levels of TNF-α and IL-6 were significantly increased in the novel NASH model group, and mice in this group exhibited histopathological features and insulin resistance reflective of NASH, i.e., macrovesicular hepatic steatosis, ballooning hepatocytes, Mallory-Denk bodies, lobular inflammation and fibrosis. The novel NASH model group presented significantly upregulated expression levels of mRNAs related to lipogenesis, oxidative stress, fibrosis and steatosis and significantly downregulated expression levels of mRNAs related to triglyceride export. We successfully established a novel experimental NASH model that exhibits similar histopathology and pathophysiology to human NASH.

Nuclear Her2 expression in hepatocytes in liver disease

Her2 is awell-known member of the epidermal growth factor receptor (EGFR) superfamily, agroup of transmembrane receptors that mediate effects of proliferation and survival and thus play an important role in tumorigenesis. EGFRs can translocate to the nucleus and may mediate DNA repair and cell cycle arrest. The aim of this study was to characterize hepatocellular Her2 expression in different liver diseases. Her2 expression was analyzed by immunohistochemistry in 674 liver biopsies. Hepatocytes often revealed anuclear and cytoplasmic Her2 expression in different liver diseases with the strongest association to alcoholic steatohepatitis. The histologic parameters of hepatocellular ballooning and the presence of Mallory-Denk bodies strongly correlated with Her2 positivity. Interestingly, in hepatocellular carcinomas (HCC) nuclear Her2 expression was frequently observed. Furthermore, Her2 positive hepatocytes showed aloss of estrogen receptor expression and increased expression of p21, acell cycle regulator, and pSTAT3, adownstream effector of nuclear Her2. Nuclear Her2 expression in hepatocytes with further metabolic and cell cycle alterations may imply aso far unknown mechanism of astress response. So far, the effects on disease course and apossible role of nuclear Her2 in progression to HCC are unclear and the subject of future research.

The Serum Biomarkers of Cardiovascular Disease Are Elevated in Patients With Non-alcoholic Fatty Liver Disease (NAFLD) With Advanced Fibrosis and Histologically-Proven Non-alcoholic Steatohepatitis (NASH): 2017 Presidential Poster Award

Introduction: NAFLD is associated with increased risk for cardiovascular disease (CVD) and CV mortality. The progressive NAFLD or NASH and especially those with hepatic fibrosis are at risk for mortality. Given that CVD is the top cause of death in NAFLD/NASH, it is possible that these subjects may share the same pathogenic environment as those with CVD. Recently, N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) and osteopontin (OPN) have been shown to be associated with CVD. Our aim was to see if these biomarkers are associated with the aggressive form of NAFLD such as NASH or significant hepatic fibrosis. Methods: The study cohort included 170 biopsy-proven NAFLD subjects who were prospectively consented and enrolled. Liver biopsies were assessed by the study hepatopathologists and graded for degree of steatosis (0-3), necroinflammation and fibrosis (0-4). Sera samples were frozen from the time of biopsy were used to measure serum levels of OPN (pg/mL), NT-proBNP (pg/mL) and adiponectin (ng/mL) using MILIPLEX® MAP assays by Luminex®. Results: Histologic NASH was seen in 52% of NAFLD and % had stage 2 or higher fibrosis. The median OPN levels were higher in NASH as compared to steatosis alone (3109 vs. 2251, p < 0.01). Additionally, adiponectin levels were lower in NASH as compared to hepatic steatosis by using quartile 4 as cutoff point (34% vs. 53%, p < 0.05). Furthermore, as compared to fibrosis stage (0-1) (2598), the median OPN levels were higher in patients with advance fibrosis (fibrosis stage ≥2) (3360, p < 0.01) as well as bridging fibrosis (3242 vs 2598, p < 0.05). Also, higher levels of OPN positively correlated with AST (r=0.17; p=0.03) and serum ferritin (r=0.28; p=0.03), while adiponectin only positively correlated with HDL (r=0.33; p < 0.01). Histologically, serum OPN significantly correlated with the presence of polymorphonuclear (r=0.24; p < 0.01), and Mallory-Denk body (r=0.28; p < 0.01) in the liver biopsy. In the multivariate analysis, serum OPN was independently associated with presence of histologic NASH in NAFLD patients (OR 2.9 [95% CI 1.2-6.7]). In contrast NT-proBNP was not detectable in both groups. Conclusion: Increased serum levels of OPN seem to be associated with presence of NASH and advanced hepatic fibrosis in patients with NAFLD. Further studies are needed to validate these findings and to determine if serum OPN can also predict presence of development of CVD in subjects with NAFLD.

Hepatic Steatosis of Unknown Etiology: What We Know and What We Donʼt

We report a case of a patient with steatosis of unknown etiology and a brief review of the state of evidence regarding steatosis. A 40-year-old man presented with 2-3 weeks of abdominal pain, nausea, vomiting, diarrhea and severely decreased oral intake, which was associated with significant weight loss. He drank 12 beers daily for more than 10 years, but denied any alcohol ingestion over the previous two months. He denied any medication or supplement use. PE was significant for jaundice and epigastric tenderness. Labs showed severe electrolyte deficiencies, Tbili 11.0, Alk phos 275, AST 108, ALT 27, Alb 2.8, INR 1.4. CT abdomen was consistent with acute hepatitis vs steatohepatitis. Hepatic workup including a viral hepatitis panel as well as all other infectious serologies were all negative. The patient underwent a right liver lobe biopsy showing underlying cirrhosis with severe steatosis and prominent steatohepatitis. The patient was managed supportively and his electrolytes improved and LFTs trended down. This patient was found to have cirrhosis likely due to alcohol use. Histology showed steatosis/steatohepatitis indicating acute liver injury as well. This was also likely secondary to alcohol-induced steatosis; however, the patient persistently denied any recent alcohol use. While, alcohol induced steatosis is thought to rapidly resolve following abstinence from alcohol there is little evidence to confirm this. The available data show that alcohol induced hepatic steatosis will resolve in anywhere from a few days to up to 6 weeks. In our case the patient endorsed abstinence for greater than two months, which if truthful, would likely indicate another cause of his steatosis. While there have been studies confirming the presence of steatosis in severely malnourished children, there has been no data evaluating liver changes in malnourished adults or the duration of starvation required to induce steatosis.Figure: CT showing diffuse hypoattenuation and enlargement of the right and caudate lobes with relative sparing of the left lobe consistent with acute hepatitis vs steatohepatitis.Figure: Liver biopsy showing histologic steatohepatitis evidenced by frequent ballooned hepatocytes, Mallory-Denk bodies, and focal mixed inflammatory infiltrates.Figure: Trichrome and reticulin staining confirm active scarring and cirrhosis.In our case the etiology of the patient's acute steatosis is unclear. It is possible that it was caused by surreptitious alcohol use despite the patient's repeated denial. Alternatively, it could have been caused by acute malnutrition in the setting of underlying liver disease. Either way, future studies are needed to determine the true duration of resolution of alcoholic steatosis in the setting of abstinence, and to evaluate the impact of starvation on hepatic steatosis and the duration of malnutrition required to cause histological changes.

Mauriac Syndrome: A Rare Cause of Lactic Acidosis in the ICU

SESSION TITLE: Student/Resident Critical Care SESSION TYPE: Student/Resident Case Report Slide PRESENTED ON: Tuesday, October 31, 2017 at 04:30 PM - 05:30 PM INTRODUCTION: Tissue hypoperfusion is the most common cause of lactic acidosis in critically ill patients. We present a rare case of persistent lactic acidosis in the absence of tissue hypoperfusion after resolution of diabetic ketoacidosis (DKA) in a patient with long standing uncontrolled diabetes mellitus type-1 (DM-1) due to glycogenic hepatopathy (Mauriac syndrome). CASE PRESENTATION: A 19-year-old male with uncontrolled DM-1 and recurrent DKA presented with abdominal pain, nausea and vomiting. Physical exam was normal except for mildly tender hepatomegaly. He was in DKA and was started on intravenous insulin in the intensive care unit. Lactic acid on presentation was 2.5 mmol/L, but increased to 7.5 mmol/L after resolution of DKA. Insulin drip was restarted and he was managed empirically for suspected sepsis. Abdominal ultrasonography demonstrated hepatomegaly with a liver span of 20 cm. Antibiotics were discontinued after a negative infectious work-up. However, the patient had persistent lactic acidosis. Liver enzymes, bilirubin, albumin and coagulation studies were normal. The patient was transitioned to subcutaneous insulin. He had documented hepatomegaly for 3 years. Hepatitis profile, thiamine level, alpha 1 antitrypsin, ceruloplasmin, Anti Nuclear Antibody, Extractable Nuclear Antigen antibody screen, anti-smooth muscle antibody, anti Liver Kidney Microsomal antibody, rheumatoid factor, anti-CCP antibody, anti-tissue transglutaminase were all negative. Liver biopsy showed edematous hepatocytes with glycogenated nuclei. Periodic Acid Schiff stain showed intense staining of glycogen in the hepatocytes with diastase pretreatment showing disappearance of glycogen. There was no steatosis, inflammation, fibrosis, necrosis or Mallory bodies. A diagnosis of glycogenic hepatopathy was made and the patient was sent home on insulin. DISCUSSION: Glycogenic hepatopathy is an under-recognized reversible cause of infiltrative hepatomegaly and lactic acidosis in patients with poorly controlled diabetes. The concomitant presence of persistent hyperglycemia and insulin leads to hepatic glycogen storage. Clinical features in adults include abdominal pain, nausea, vomiting, hepatomegaly, and lactic acidosis. Lactic acidosis is due to decrease in gluconeogenesis and failure to convert pyruvate into glucose and can be acutely worsened by high dose insulin. Liver biopsy is the definitive method of diagnosis. Rigorous glucose control reverses this condition. CONCLUSIONS: Awareness of glycogenic hepatopathy should help the clinician to not treat lactic acidosis based on numbers and expose patients to unnecessary sepsis treatment in the right clinical setting. Reference #1: Ross, J. J., et al. (2011). “Interactive medical case. A sweet source of abdominal pain.” N Engl J Med 364(15): e30 Reference #2: Deemer, K. S. and G. F. Alvarez (2016). “A Rare Case of Persistent Lactic Acidosis in the ICU: Glycogenic Hepatopathy and Mauriac Syndrome.” Case Rep Crit Care 2016: 6072909. DISCLOSURE: The following authors have nothing to disclose: Aditya Kotecha, Dongping Shi, Mohamed Siddique, Saraschandra Vallabhajosyula, Vivek Iyer, Geetha Krishnamoorthy No Product/Research Disclosure Information

Histopathology, grading and staging of nonalcoholic fatty liver disease.

Nonalcoholic fatty liver disease (NAFLD) is the liver disease associated with obesity, diabetes and the metabolic syndrome. Although steatosis is a key histological feature, liver biopsies of patients with NAFLD can show a wide range of other findings, including portal and lobular inflammation, ballooning and apoptotic hepatocellular injury, Mallory-Denk bodies, megamitochondria and fibrosis. Nonalcoholic steatohepatitis (NASH) is a progressive subtype of NAFLD first defined by analogy to alcoholic hepatitis. The characteristic finding in NASH is ballooning hepatocellular injury. The fibrosis pattern is distinctive, with perisinusoidal fibrosis around the central veins being the first manifestation of fibrosis. Young children may have an alternate pattern of progressive NAFLD characterized by a zone 1 distribution of steatosis, inflammation and fibrosis. Several grading and staging systems exist for use in natural history studies and clinical trials, each with some advantages and disadvantages. These include the Brunt system, the NASH CRN system and the SAF system. Each of these systems has been applied to clinical studies permitting correlation of laboratory and demographic observations with histological findings.

The role of Tec kinase signaling pathways in the development of Mallory Denk Bodies in balloon cells in alcoholic hepatitis

Several research strategies have been used to study the pathogenesis of alcoholic hepatitis (AH). These strategies have shown that various signaling pathways are the target of alcohol in liver cells. However, few have provided specific mechanisms associated with Mallory-Denk Bodies (MDBs) formed in Balloon cells in AH. The formation of MDBs in these hepatocytes is an indication that the mechanisms of protein quality control have failed. The MDB is the result of aggregation and accumulation of proteins in the cytoplasm of balloon degenerated liver cells. To understand the mechanisms that failed to degrade and remove proteins in the hepatocyte from patients suffering from alcoholic hepatitis, we investigated the pathways that showed significant up regulation in the AH liver biopsies compared to normal control livers (Liu et al., 2015). Analysis of genomic profiles of AH liver biopsies and control livers by RNA-seq revealed different pathways that were up regulated significantly. In this study, the focus was on Tec kinase signaling pathways and the genes that significantly interrupt this pathway. Quantitative PCR and immunofluorescence staining results, indicated that several genes and proteins are significantly over expressed in the livers of AH patients that affect the Tec kinase signaling to PI3K which leads to activation of Akt and its downstream effectors.

Aggressive non-alcoholic steatohepatitis following rapid weight loss and/or malnutrition

While non-alcoholic steatohepatitis is a slowly progressive disease, patients may rarely present in acute liver failure. We describe six patients who developed severe hepatic dysfunction following rapid weight loss or malnutrition. Rapid weight loss (18 to 91 kg) occurred after Roux-en-Y gastric bypass in four patients and starvation-like dieting or hypoalbuminemia was noted in two patients. Four patients either died or received an urgent liver transplant. Pathologic findings were characterized by advanced alcoholic steatohepatitis-like features, including extensive/circumferential centrizonal pericellular fibrosis, central scar with perivenular sclerosis/veno-occlusion with superimposed hepatocellular dropout, abundant/prominent hepatocellular balloons, and numerous Mallory–Denk bodies, but there was no history of excess alcohol consumption. This study characterizes clinicopathologic features of aggressive non-alcoholic steatohepatitis following rapid weight loss or malnutrition, which should be included in the differential diagnosis with alcohol when a patient is considered for liver transplantation. The mechanism of liver injury in aggressive steatohepatitis is unknown, but rapid fat mobilization in obese patients may potentially cause oxidative stress to the liver and further study is needed to determine if there is a genetic predisposition to this form of injury and if antioxidants may protect the liver during rapid weight loss/malnutrition.

Up regulation of Spleen Tyrosine Kinase in ballooned hepatocytes with Mallory‐Denk Bodies in Alcoholic Liver Disease

Liver injury from alcohol abuse causes balloon hepatocytes and MDB formation. Mallory‐Denk bodies (MDBs) are found in 70% to 75% of patients with alcoholic hepatitis (AH). MDBs are composed of intracellular aggregations of misfolded proteins in ballooned hepatocytes. To determine the mechanism of balloon degeneration and MDB formation in hepatocytes, we evaluated the role of spleen tyrosine kinase (Syk) which is associated with transmembrane receptors to mediate numerous signal transductions downstream of these receptors. Spleen tyrosine kinase is widely expressed in hematopoietic cells and modulates several signaling pathways including PIK3/AKT and p7056 pathways. These pathways are important in regulating the cell cycle and are actively involved in mediating cell adhesion. Dysregulation of the PI3K/Akt pathway is implicated in a number of human diseases including cancer, diabetes, cardiovascular disease and neurological diseases. In this study, liver biopsy sections fixed in formalin and embedded in paraffin (FFPE) were used from patients with alcoholic hepatitis (AH). The results show that the expression of Syk protein is up regulated by RNAseq and real time PCR analyses in the alcoholic hepatitis patients compared to controls. The results were also supported by using IHC fluorescent intensity staining morphometric system. Morphometric quantification of fluorescent intensity showed a two fold increase in Syk in the cells forming MDBs compared to surrounding normal hepatocytes. Interestingly, the upregulation of Syk protein is co‐localized with ubiquitinated proteins in the cytoplasm of balloon cell hepatocytes which have formed MDBs. This observation demonstrates the role of Syk as a potential multifunctional target in protein quality control mechanism of hepatocytes when ER stress is activated.