Journal of the Louisiana State Medical Society
P athology I mage of the M onth
Altered Mental Status, Alcohol Abuse, and Hyperammonemia
Theresa Nuttli, MD; Robin R. McGoey, MD
A 74-year-old woman with a past medical history of diabetes, hypertension, and alcohol abuse was brought to the emergency department and subsequently admitted to the intensive care unit with an altered mental status andweakness. Laboratories revealed acute renal failure (BUN 15 mg/dL, creatinine 2.5 mg/dL), elevated serum transaminase (AST of 83 IU/L), hyperammonemia (187 ug/dL), andmarked normocytic anemia requir- ing transfusion of three units of packed red cells (hemoglobin 4.3 g/dL; hematocrit 13.1%). Blood ethanol level at the time of admission was <5 mg/dL, and full urine toxicology was negative. Alcohol abuse was reported to consist of, on average, “one pint of gin per day.” Her hospital course was nine days and included complete inotropic blood pressure support and intubation. On the ninth day, she was declared dead, and authorization for an unrestricted autopsy was granted by the coroner. At autopsy, two liters of serous ascitic fluid was drained from the peritoneal cavity, and non-ruptured, distended varices were identified at the gastroesophageal junction. Additional findings included changes compatible with hypertensive cardiovas- cular disease, including hypertrophy of the interventricular cardiac septum and glomerulosclerosis along with renal atrophy. The liver weighed 1,300 grams (normal 1,475 gm ± 362) and was markedly discolored yellow-tan. Its parenchyma was more firm than usual. Representative microscopic sections from the dece- dent’s liver are shown in the image below. What are the pink inclusions seen within the hepatocytes’ cytoplasm, and with what liver diseases are they associated?
Figure 1: (A - left) Liver cells showing eosinophilic twisted rope appearing Mallory-Denk bodies in the hepatocyte cytoplasm, hovering around the cell’s nucleus (hematoxylin-eosin, original magnification x40). (B - right) Immunohistochemistry with an anti- pan cytokeratin antibody showing strong staining of Mallory-Denk bodies (original magnification x40).
46 J La State Med Soc VOL 166 January/February 2014
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