Case Reports in Hepatology

Xanthogranulomatous cholecystitis (XGC) is a rare benign chronic inflammatory disease of the gallbladder that often presents as cholecystitis and can mimic gallbladder carcinoma. Distinguishing XGC from gallbladder cancer preoperatively is challenging. We present a case of a 62-year-old male who presented with features of carcinoma gallbladder in the CECT abdomen and MRCP. Intraoperatively, there was a mass in the gallbladder and extension into the adjacent structures with involvement of the hepatic artery, 1^st part of the duodenum, portal vein, and hepatic flexure of the colon, and thus a palliative cholecystectomy was done. The histopathological report came out as XCG. The case aims to outline the clinical presentation of XGC and differentiate it from carcinoma gallbladder.

Liver test abnormalities have been described during severe acute respiratory syndrome coronavirus (SARS-CoV)-2 infection causing coronavirus disease 2019. Most of them consist of elevation of the aminotransferases that resolve once the infection subsides. There are several reports of autoimmune hepatitis developing after vaccination against COVID-19 and one case of autoimmune hepatitis following COVID-19 infection. We present a patient that was not vaccinated against COVID-19 and developed resistant de novo autoimmune hepatitis following COVID-19 infection requiring aggressive immunosuppression.

Spontaneous bacterial peritonitis is a known complication of patients with decompensated cirrhosis and ascites. It is differentiated from secondary bacterial peritonitis by the absence of an intraabdominal source of infection. We present a 56-year-old man with alcoholic cirrhosis who underwent multiple paracenteses that yielded fluid with progressively increasing neutrophil counts and several different organisms, recurring despite numerous treatments for SBP. Eventually, a computed tomography (CT) of the abdomen and the pelvis revealed a large intraabdominal abscess (22 × 13 cm) treated with an ultrasound-guided drain and IV antibiotics. Recurrent episodes of SBP despite appropriate antibiotics should raise suspicion for secondary bacterial peritonitis. It is crucial to differentiate SBP from secondary bacterial peritonitis as the mortality of the latter is much higher without prompt treatment. Appropriate antibiotic regimens, prompt surgical treatment, and postoperative care are crucial to improving clinical outcomes in these patients.

Lenvatinib, an oral small-molecule multiple tyrosine kinase inhibitor (TKI), has been approved for first-line therapy for unresectable hepatocellular carcinoma (HCC). Proteinuria is one of the most common adverse events associated with lenvatinib treatment. We reported a 67-year-old Thai female was diagnosed with NASH cirrhosis and HCC BCLC B with TACE refractoriness. She received 8 mg of lenvatinib for 2 weeks and began to experience worsening hypertension, bilateral pleural effusion, pedal edema, hypoalbuminemia, hypercholesterolemia, and proteinuria. After exclusion of all possible causes, lenvatinib-induced nephrotic syndrome (NS) was diagnosed. One week after discontinuing the drug, her symptoms gradually improved. To date, there have been only a handful of reported cases of lenvatinib-induced nephrotoxicity. We report herein the case of lenvatinib-induced NS in a cirrhotic patient with HCC with resolution of symptoms in a short period after drug discontinuation. In addition, we reviewed all reported cases of lenvatinib-induced nephrotoxicity.

Immunoglobulin G subclass 4 (IgG-4)-related disease (IgG4-RD) is an uncommon immune-mediated, fibro-inflammatory disease which has garnered recognition as a systemic condition. One manifestation of the disease in the hepatobiliary system is the development of hepatic inflammatory pseudotumors. These benign tumors are often misdiagnosed as malignant tumors and undergo unnecessary hepatic resections. We present a case of IgG4-related hepatic inflammatory pseudotumor (IPT) mimicking a Klatskin tumor. A high degree of clinical suspicion and extensive workup is imperative in reaching the correct diagnosis. IgG4-related inflammatory pseudotumor is a rare entity, but an important consideration in evaluating hepatic tumors.

Teriflunomide is a pyrimidine synthesis inhibitor used in the treatment of multiple sclerosis that has in rare instances been associated with liver toxicity, though there are few documented cases. Here, we report a case of probable teriflunomide-induced liver injury as assessed for causality using the updated RUCAM. The liver injury occurred approximately nine months after teriflunomide initiation and improved with discontinuation of the drug and treatment with cholestyramine.