1. Drug/Toxin Mediated Injury Neil Theise, MD Depts. of Pathology and Medicine (Digestive Diseases) Beth Israel Medical Center – Albert Einstein College of Medicine New York City

8. THEREFORE (KEY CONCEPT!!!): IF YOU HAVE SIGNS OF LIVER DISEASE CLINICALLY OR IN A BIOPSY, DRUG TOXICITY IS ON YOUR DIFFERENTIAL!!!

10. Examples

13. Case 1: 42 y.o. woman with HCV. Biopsy for staging and grading.

18. Case 1: Dx: 1. Chronic hepatitis, mildly active with focal, mild portal fibrosis, compatible with hepatitis C. 2. Stellate cell lipidosis suggestive of hypervitaminosis A or other retinoid use.

19. Case 2: 28 y.o. man receives Ompeprazole; one week later notices yellow eyes. ALT/AST: 70/83 Alk Phos: 2x normal Bilirubin: 11.2

24. Case 2: Dx: Acute cholestasis, marked, compatible with Omeprazole toxicity.

25. Case 3 2008: Now 22 years old, returns to emergency room with identical clinical picture: nausea, vomiting, fatigue and jaundice; ALT/AST >8000 Again, negative for: HAV, HBV, HCV ANA, AMA, ASMA, anti-LKM1 Drugs or over the counter medications, etc. Again, ceruloplamin and iron indices all normal. Again, clinically: Fulminant failure of unknown cause. Receives supportive care AND a liver biopsy. Again, patient recovers completely and goes home well.

26. Case 3 2004: Without prior or family history of liver disease, this 18 year old female presents with nausea, vomiting, fatigue and jaundice; ALT/AST >6000 Negative for: HAV, HBV, HCV ANA, AMA, ASMA, anti-LKM1 Drugs or over the counter medications, etc. Ceruloplamin and iron indices all normal. Clinically: Fulminant failure of unknown cause. Receives supportive care while awaiting donor organ, but patient recovers completely and is taken off transplant list; goes home well.

35. Case 3: Dx: Features of markedly active hepatitis, ? acute vs. chronic, ? drug/toxin mediated injury