Khan Zohayr A, Ellington Abigail L, Abraham Wakeem L, Gui Xianyong, Lippert William C
Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, USA.
Pathology, Wake Forest University School of Medicine, Winston-Salem, USA.
Cureus. 2025 Aug 1;17(8):e89223. doi: 10.7759/cureus.89223. eCollection 2025 Aug.
A 37-year-old female was hospitalized for acute liver injury, presenting a diagnostic challenge that ultimately led to a diagnosis of alcohol-associated steatohepatitis (ASH). Steatohepatitis is a state of liver inflammation with fat accumulation and has several potential etiologies, including metabolic dysfunction-associated, alcohol-associated, drug-induced, autoimmune, and viral causes. A definitive diagnosis often requires a thorough clinical history, laboratory and imaging studies, and, in some cases, a liver biopsy. Our patient, with a history of gastroesophageal reflux disease, alcohol-use disorder, obesity, and systemic lupus erythematosus, presented with a one-week history of abdominal pain, jaundice, conjunctival icterus, and hepatomegaly without altered mental status. Laboratory results showed a total bilirubin of 12.5 mg/dL, aspartate aminotransferase of 237 U/L, alanine aminotransferase of 129 U/L, alkaline phosphatase of 424 U/L, and an international normalized ratio of 1.2. Right upper quadrant ultrasound revealed no biliary obstruction. Viral and autoimmune panels, as well as immunoglobulins, were unremarkable. Ceruloplasmin was low (0.09 g/L), 24-hour urinary copper was elevated (40 µg/24 hour), and slit-lamp examination was negative for Kayser-Fleischer rings. Liver biopsy revealed severe steatosis with prominent Mallory-Denk bodies, bridging fibrosis, and portal tract inflammatory infiltrates. These histologic features, together with a positive phosphatidylethanol test, led to the diagnosis of ASH. This case highlights an interesting diagnostic challenge of acute liver injury. Although ceruloplasmin was low and 24-hour urinary copper was elevated, these levels did not meet the diagnostic criteria for Wilson's disease. Liver biopsy suggested ASH, despite the patient reporting cessation of alcohol use. In cases of acute liver injury where history, labs, and imaging studies are inconclusive, liver biopsy is crucial for diagnosis. Treatment for ASH includes abstinence from alcohol and corticosteroids.
一名37岁女性因急性肝损伤入院，这带来了诊断难题，最终诊断为酒精性脂肪性肝炎（ASH）。脂肪性肝炎是一种伴有脂肪堆积的肝脏炎症状态，有多种潜在病因，包括代谢功能障碍相关、酒精相关、药物性、自身免疫性和病毒性病因。明确诊断通常需要详尽的临床病史、实验室及影像学检查，在某些情况下还需要进行肝活检。我们的患者有胃食管反流病、酒精使用障碍、肥胖和系统性红斑狼疮病史，出现腹痛、黄疸、结膜黄疸和肝肿大一周，精神状态无改变。实验室检查结果显示总胆红素为12.5mg/dL，天冬氨酸转氨酶为237U/L，丙氨酸转氨酶为129U/L，碱性磷酸酶为424U/L，国际标准化比值为1.2。右上腹超声检查未发现胆道梗阻。病毒和自身免疫指标以及免疫球蛋白均无异常。铜蓝蛋白水平低（0.09g/L），24小时尿铜升高（40μg/24小时），裂隙灯检查未见Kayser-Fleischer环。肝活检显示严重脂肪变性，有明显的Mallory-Denk小体、桥接纤维化和门管区炎性浸润。这些组织学特征，加上磷脂酰乙醇试验阳性，导致诊断为ASH。该病例凸显了急性肝损伤有趣的诊断挑战。尽管铜蓝蛋白水平低且24小时尿铜升高，但这些水平未达到威尔逊病的诊断标准。尽管患者报告已戒酒，但肝活检提示为ASH。在病史、实验室检查和影像学检查结果不明确的急性肝损伤病例中，肝活检对诊断至关重要。ASH的治疗包括戒酒和使用皮质类固醇。
