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Sang Oh, MD, and Nezam H. Afdhal, MD
March 12, 2001

A 43-year old female with past surgical history of cadaveric renal transplantation in 1989, presents with a two-week history of progressive jaundice, nausea, vomiting and fatigue.

What is the diagnosis and what are the recommendations for further tests and management?

History of Present Illness
The patient initially presented with above symptoms to another hospital, where she was found to have AST 325 IU/L, ALT 236 IU/L, alkaline phosphotase 221 IU/L and total bilirubin of 25 mg/dL. She also had mild right upper quadrant discomfort that was constant and non-radiating. However, her main complaints were progressive jaundice and fatigue. She had an abdominal ultrasound and computed tomography (CT) scan that revealed only mildly heterogeneous liver, without biliary ductal dilatations or focal lesions in her liver.

The patient had noticed dark urine but no change in bowel movements. She denied any fever, chills, pruritus, recent sick contacts or travel. Her renal graft has been functional on a stable dose of immunosuppression for many years.

Past Medical History
  • Cadaveric renal transplant in 1989 (renal failure thought to be due to long standing hypertension)
  • Hypertension
  • Hypercholesterolemia


1. Azathioprine 50 mg BID
2. Cyclosporine 100mg BID
3. Prednisone 10 mg QD
4. Furosemide 20 mg QD
5. Atenolol 50mg QD
6. Nifedipine 30 mg QD

Physical Exam
The patient appeared in no apparent distress, with blood pressure of 136/60, heart rate of 105 and temperature of 99 degrees F. She had marked
jaundice. Oral mucous membranes were dry with evidence of oral thrush. Heart and lung examinations were within normal limits.

Her abdominal examination revealed distended abdomen with moderate ascites, mild right upper quadrant tenderness on deep palpation, but no evidence of rebound tenderness. She had active bowel sounds and no evidence of hepatosplenomegaly. 1+ peripheral edema was noted. No stigmata of chronic liver disease such as palmar erythema, spider angiomata were noted.

Laboratory Studies
Initial studies revealed the following:

ALT 288 IU/L WBC 18.1 K/µL
AST 408 IU/L HCT 33.3 %
Alk Phos 221 IU/L PT 19.3 seconds
T. Bili 27.9 mg/dl INR 2.5
Albumin 2.5 g/dl PTT 40.0 seconds

An MRI/MRCP was performed, which revealed moderate ascites with no biliary ductal dilatation.

MRI image showing moderate ascites
MRI image showing moderate ascites

The liver was normal in size, but parenchyma was diffusely heterogeneous without focal mass. The gallbladder was slightly dilated without evidence of acute cholecystitis.

Subsequent viral serologies showed the following:

HAV Positive HBsAg Positive
HAV (IgM) Negative HBsAb Equivocal
HCV Negative HBcAb Positive
HCV RNA Negative HBcAb (IgM) Negative
    HBeAg Positive
    HBeAb Negative
    HBV DNA 56 million copies/ml

What is the diagnosis and what are the recommendations for further tests and management?

This Case of the Month is closed.