Athol J. Ware

Etiology of Liver Disease in Renal-Transplant Patients

The etiology of 72 episodes of liver disease that developed in 62 of 162 renal-transplant recipients was evaluated. Infection with hepatitis B virus was a minor problem, and none of our patients had evidence of infection with hepatitis A. Cytomegalovirus infection was ubiquitous in the population and probably accounted for many episodes of acute liver disease. This agents role in causing chronic hepatitis is less secure. Infections with other viruses including Epstein-Barr virus, adenovirus, and the herpes viruses were only rarely associated with hepatic disease. Azathioprine was responsible for some episodes of acute cholestasis but could not be incriminated as a direct cause of chronic disease. A cause could be identified for the majority of episodes of acute hepatic dysfunction, but the cause of most of the chronic hepatitis remains undetermined. It is likely that infection with non-A, non-B hepatitis virus accounts for much of this serious, often fatal, complication of renal transplantation.

Disseminated sporotrichosis with extensive cutaneous involvement in a patient with AIDS

Sporotrichosis most commonly presents as a localized, lymphocutaneous infection that follows trauma, such as an injury from a rose thorn. In patients infected with HIV, it may be widespread and disseminated. We describe a patient with AIDS who developed disseminated sporotrichosis, a rare opportunistic fungal infection that may affect these patients. The condition remained undiagnosed because of failure to recognize characteristic histopathologic findings and failure of clinicians to interface closely with the microbiology laboratory. The condition was difficult to treat, requiring systemic administration of amphotericin. While localized sporotrichosis is an innocuous disorder that responds well to therapy, in immunocompromised hosts, it is potentially life-threatening and may require prolonged therapy with potentially toxic medications such as amphotericin B. It is important that clinicians be aware of the presentation of this unusual opportunistic infection and that they maintain close communication with pathology and clinical microbiology laboratories to ensure that proper stains and cultures are performed to avoid potential misdiagnosis.

Prognostic Significance of Subacute Hepatic Necrosis in Acute Hepatitis

A retrospective analysis has been made of 57 patients with subacute hepatic necrosis demonstrated on a liver biopsy obtained during the course of an episode of acute hepatitis. Fourteen patients have been lost to follow-up. One patient died acutely with massive hepatic necrosis, while 8 have developed chronic active liver disease. Two of nine biopsies subsequently performed on patients who had shown complete clinical and biochemical resolution revealed an inactive postnecrotic cirrhosis. The incidence of these complications developing in patients with subacute hepatic necrosis was approximately 30%. These findings add qualitative support to the position that liver biopsy findings bear important prognostic value in patients with acute hepatitis.

Spectrum of Liver Disease in Renal Transplant Recipients

An evaluation of the hepatic dysfunction which occurred in the post-transplant period in 31 of 82 renal transplant recipients managed at Parkland Memorial Hospital has revealed three different patterns of liver disease. Two patients died in acute liver failure during an acute fulminant illness. Eight other patients suffered an acute, anicteric, and completely reversible hepatic disorder. Twenty-one patients have been afflicted with a chronic form of liver disease which, in a least 5, has progressed to an active cirrhosis. Infection with cytomegalovirus and other viruses is probably responsible for most of the liver disease we have observed in these patients, while hepatotoxicity related to therapy with azathioprine and other drugs has played only a minor role.

A Prospective Trial of Steroid Therapy in Severe Viral Hepatitis The Prognostic Significance of Bridging Necrosis

A prospective, double-blinded, randomized trial of corticosteroid therapy in patients with severe acute viral hepatitis has been conducted. At the same time, we have examined the prognostic significance of the presence of bridging necrosis in liver biopsies obtained from such patients as well as the predictive value of certain serologic markers. Forty-two of the 77 patients admitted to the trial were shown to have bridging necrosis on their initial biopsies. Two patients progressed to death with massive hepatic necrosis, while 5 patients developed chronic liver disease. A complicated course could not be predicted by the initial biopsy findings nor by any of the serologic markers assessed. We could not identify any clinical or epidemiologic features with prognostic impact. No advantage was demonstrated to be associated with the use of corticosteroids early in the course of severe viral hepatitis.

Cirrhosis After Repeated Trichloroethylene and 1,1,1-Trichloroethane Exposure

Acute hepatotoxicity has been described in patients exposed to either trichloroethylene or 1,1,1-trichloroethane, but there have been no previous reports of chronic liver disease induced by these agents. We describe a patient who developed cirrhosis and portal hypertension after repeated bouts of acute hepatotoxicity caused by trichloroethylene and a final episode of 1,1,1-trichloroethane-induced liver injury.

Resolution of Chronic Parvovirus B19-Induced Anemia, by Use of Highly Active Antiretroviral Therapy, in a Patient with Acquired Immunodeficiency Syndrome

We present what is, to our knowledge, the second case report of a patient with acquired immunodeficiency syndrome and transfusion-dependent anemia caused by persistent infection with parvovirus B19. The patients anemia was successfully treated, and she demonstrated serologic evidence of eradication of parvovirus after having received effective therapy for human immunodeficiency virus infection.

Didanosine-induced hepatitis.

TO THE EDITOR: The hepatopathy associated with didanosine (ddI) and other nucleoside analogs has been varied but, in most instances, has been described as some form of steatosis with minimal hepatic necrosis (1, 2, 3, 4, 5, 6, 7, 8, 9). We present a patient who developed clinically severe liver injury while taking ddI. Liver disease recurred on re-exposure to the drug, and a liver biopsy showed extensive hepatocellular necrosis with collapse-fibrosis and inflammation.