Epithelioid granulomas hepatitis c virus

Epithelioid granulomas hepatitis c virus

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  ANNALS OF HEPATOLOGY Volume 1 Number 2 April-June 2002 Article: Epithelioid granulomas in a patient with hepatitis C virus Copyright © 2002: Mexican Association of Hepatology Otras secciones de Others sections in este sitio: this web site: ☞ Índice de este número ☞ Contents of this number ☞ Más revistas ☞ More journals ☞ Búsqueda ☞ Search edigraphic.com
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  R Pichardo-Bahena etal. / Epithelioid 2002; 1(2): April-June: 91-93 hepatitis C virus Annals of hepatology granulomas in a patient with 91 Case Report Annals of hepatology Epithelioid granulomas in a patient with hepatitis C virus Raúl Pichardo-Bahena1 and Nahum Méndez-Sánchez2 Abstract use of intravenous drugs and we found no other co-infec- tions by laboratory tests. Hepatitis C virus infection causes an epidemic disease. The morphologic aspects of hepatitis C infection Discussion (HCV) are well established with regards to necroin- flammatory processes and consequences like fibrosis, The morphological aspects of HCV infection have cirrhosis, and related neoplasms. However, the pres- been described during the past three decades.4-8 These dif- ence of epithelioid granulomas has not been well de- fering morphological and clinical diseases were first re- scribed for this infection. We report a patient with ported as non-A, non-B hepatitis.9-11 In 1989, the viral HCV and granulomas without any other co-infection agent, HCV, was identified and isolated,12,13 and almost all or history of drug abuse. cases of non-A non-B hepatitis were related to this viral agent. Most histopathological changes have been de- Key words: Hepatitis C, granulomas tuberculosis. scribed following percutaneous or transjugular biopsies. The histopathological changes are reported according to Introduction the hepatic area affected: the portal and periportal areas and the hepatic parenchyma. The disease is described in terms of Cases of granulomatous hepatitis are well characterized the duration of chronic hepatitis, with activity in different in terms of their infective and idiopathic etiology and asso- grades,7,14,15 steatosis and fibrosis. The spectrum of histologi- ciation with drugs and HIV co-infection.1-3 Etiologically, cal changes is related to the degree of lymphocyte or lympho- granulomas may be infective or non-infective. The infective plasmocyte infiltration into the liver, and to the necroinflam- causes include bacteria, fungi, mycobacteria, and viruses matory damage caused. The pathological and pharmacologi- (Table I). In the non-infective types, the causes may be sar- cal investigations aim to evaluate the fibrosis and arrest it. coidosis, drugs or idiopathic (Table II). The drug causes in- How can we explain the prevalence of granulomas in clin- clude non-steroidal anti-inflammatory drugs, antibiotics, ical hepatitis C? This is an item not well described for these contrast medium, anti-convulsive agents, and drugs used patients, because publications have not identified granulomas for treatment of HCV infection. Thus, there is an extensive in liver biopsies of patients with HCV, by Tru-cut needle, spectrum of etiologies. trans-jugular or open biopsies. However, other investigators have reported granulomas in patients with HCV infection Case report without any other infectious agent, such as in liver-transplant patients with viral flare-ups16 and following HIV infection. A 40-year-old male Mexican was admitted to hospital Only a few articles have mentioned the presence of epi- for evaluation of hypertransaminasemia (alanine amino- thelioid granulomas in the spectrum of chronic inflamma- transaminase 63 U/L; aspartate aminotransferase 40 U/L) tion in patients with HCV.17 Morphologically, granulomas and painful neck and shoulders. Chronic active hepatitis are associated with central necrosis surrounded by a rim of caused by the hepatitis C virus was diagnosed. Serum lymphocytes, similar to that observed in cases of tuberculo- HCV RNA concentration was 1,000,000 copies/mL, and sis. This is our only experience of hepatic granulomas in a the viral genotype was 1b. Further examination was insti- patient with HCV infection unrelated to HIV infection, tuted because of the simultaneous finding of granulomas drugs or drug abuse (Figure 1). In this patient, in the open in a liver biopsy. The patient did not give a history of any liver biopsy the hallmark histological changes of liver were the presence of epithelioid granulomas with central necrosis 1 Department of Pathology. edigraphic.com encircled by lymphocytes and fibrosis. No birefringent ma- 2 Biomedical Research and The Liver Unit. terial or bile extravasations were detected. No acid-fast or- ganism (AFO) was demonstrated. However, the morpho- Address for correspondence: Raúl Pichardo-Bahena. logical changes were suggestive of tuberculosis granulo- Medica Sur Clinic & Fundation Puente de Piedra Num. 150. Colonia mas. Emile et al.17 described five patients in whom no Toriello Guerra, Tlalpan, C.P. 1505. Mexico, City, Mexico. AFOs were demonstrated.
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  92 Annals of hepatology 1(2) 2002: 91-93 Both tuberculosis and HCV infections are diseases of global distribution, with high prevalence and with the char- acteristics of epidemics and endemic diseases. The pres- ence of HCV infection and epithelioid granulomas in liver without any AFO demonstrated by histological techniques requires further study with polymerase chain reaction (PCR) technique to eliminate the other possible causes. Table I. List of the etiologies of granulomas.* Actinomycosis Leprosy Adenoma, liver cell Leukemia, hairy cell Alcoholic fatty liver Listeriosis Ascariasis Lymphoma, Hodgkin’s and non- Hodgkin’s Bacterial sepsis Melioidosis Figure 1. Hepatic granuloma, with central necrosis. Boutonneus fever Mucolipidosis II Brucellosis Mycobacterium avium-intracellulare infection Candidiasis Nocardiosis Cat-scratch disease Nonalcoholic steatohepatitis (se- condary to jejunoileal bypass) Chronic granulomatous disease Nonspecific reactive hepatitis of childhood Coccidioidomycosis Paracoccidioidomycosis Cryptococcosis Penicilliosis Cytomegalovirus infection Polyarteritis nodosa Drugs/toxins Primary biliary cirrhosis Eosinophilic gastroenteritis Q fever Epstein-Barr virus infection Rheumatoid arthritis Farber’s lipogranulomatosis Salmonellosis Fascioliasis Sarcoidosis Foreing body giant cell reaction Schistosomiasis Hepatocellular cercinoma, Syphilis, congenital, secondary and fibrolamellar type tertiary Histoplasmosis Systemic lupus erythematosus Hydatid cyst Toxoplasmosis Idiopathic granulomatous hepatitis Tuberculosis Inflammatory pseudotumor Visceral larva migrans Langherhan’s cell histiocytosis Whipple’s disease Leishmaniasis Zygomycosis Figure 2. Central necrosis encircled by epithelioid histiocytes. * From Kanel GC, Korula J: Granulomas, in Kanel and Korula, Liver Biopsy Evalua- tion. Philadelphia, Penn, Saunders 2000, p 43. Table II. List of the drugs causing granulomas.** Allopurinol Dimethicone Oxacillin Ranitidine Alpha-methyldopa Disopyramida Oxyophenbutaz-one Silica Aspirin Feprazone Oxiphenisatin Succinylsulfathiazole Bacille Calmette-Guérin therapy or vaccination Glibenclamide Papaverine Sulfadiazine Barium Gold sodium thiomalate Penicillin Sulfadimehoxine Beryllium Gree-lipped mussel Phenazone Sulfadoxine-pyrimethamine Carbamazepine Halogenated hydrocarbons Phenprocoumon Sulfanilamide Carbutamide Isoniazid Phenylbutazone Sulfasalazine Cephalexin Mestranol Polyvinyl pyrrolidone Sulfonamides Chlorpromazine Metolazone Prajmalium Sulfonylurea agents Chlorpropamide Mineral oil Procainamide Thorotrast (thorium dioxide) Copper Nitrofurantoin Procarbazine Tocainide Dapsone Norethyndrone Pronestyl Tolbutamide Diazepam Norethynofrel Quinidine Trichlormethiazide Diltiazem Norgestrel Quinine Trimethroprim-sulfamethoxazole ** From Kanel GC, Korula J: Granulomas, in Kanel and Korula Liver Biopsy Evaluation. Philadelphia, Penn, Saunders 2000, p 221.
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