WBR0627
| Author | [[PageAuthor::Mugilan Poongkunran M.B.B.S [1]]] |
|---|---|
| Exam Type | ExamType::USMLE Step 3 |
| Main Category | MainCategory::Primary Care Office |
| Sub Category | SubCategory::Gastrointestinal |
| Prompt | [[Prompt::A 40 year old male, comes to the office with complaints of fatigue and malaise for the past few weeks. He is a known case of chronic hepatitis C who underwent allograft liver transplantation 6 months ago. He is currently on immunosuppressive agents with cyclosporine and tacrolimus. He denies any other complaints. He denies smoking and consuming alcohol. On examination his temperature is 37.7 C, blood pressure is 130/70 mmHg, pulse is 102/min and respiration's are 16/min. Abdomen is soft and non-tender with no organomegaly. Other system examinations are normal . His lab results are Hb:7 g/dl, hematocrit : 33, Na:135 mEq/L, K: 3.5 mEq/L, Cl:104mEq/L, Bi: 24 mEq/L, BUN: 30 mg/dl, glucose:98 mg/dl, Mg: 1mg/dl and Ca: 8mg/dl. The liver fuction test results are as follows:
Alanine aminotransferase : 200 U/L Aspartate aminotransferase : 290 U/L Alkaline phosphatase : 120 U/L Total bilirubin : 1 mg/dl Serum albumin : 3.6 g/dl Prothrombin time : 12 sec A liver biopsy is done and it reveals portal tract inflammation with piecemeal necrosis and scatterred lobular inflammation. What is the most likely diagnosis in this patient?]] |
| Answer A | AnswerA::Hepatic artery thrombosis |
| Answer A Explanation | [[AnswerAExp::Incorrect : Hepatic artery thrombosis presents with elevated ALP and GGT levels.]] |
| Answer B | AnswerB::Allograft rejection |
| Answer B Explanation | [[AnswerBExp::Incorrect : Abnormalities in the hepatic biochemical tests in the short-term post-transplant period are frequently a manifestation of preservation injury or acute cellular rejection. Preservation injury usually manifests with elevation of the alkaline phosphatase and GGT, without a significant increase in total bilirubin. By contrast, elevation of transaminases (alanine aminotransferase [ALT] and aspartate aminotransferase [AST]) together with rising bilirubin level and/or GGT should raise concern for acute cellular rejection.]] |
| Answer C | AnswerC::Immunosppresive agent toxicity |
| Answer C Explanation | [[AnswerCExp::Incorrect : Immunosuppressive agent toxicity includes nephrotoxicity, neurotoxicity, hypertension, gingival hyperplasia, susceptibility to opportunistic infections.]] |
| Answer D | AnswerD::Recurrent Hepatitis C infection |
| Answer D Explanation | [[AnswerDExp::Correct : Almost all patients with liver transplantation have a documented evidence of hepatitis C recurrence.]] |
| Answer E | AnswerE::Cytomegalovirus infection |
| Answer E Explanation | [[AnswerEExp::Incorrect : Cytomegalovirus remains the most important viral infection in liver transplant recipients. CMV disease can present with a variety of symptoms, the most common of which are fever, leukopenia, thrombocytopenia, malaise, and arthralgias . Less frequent manifestations include pneumonia, gastroenteritis, hepatitis, and retinitis.]] |
| Right Answer | RightAnswer::D |
| Explanation | [[Explanation::Abnormalities of liver function test after liver transplantation is common and can be attributed to lot of factors like immunosuppressive agent toxicity, hepatitis C recurrence, cytomegalovirus, acute cellular rejection, hepatic artery thrombosis, ischemic reperfusion injury etc. However Almost all patients with liver transplantation have a documented evidence of hepatitis C recurrence. Educational Objective: |
| Approved | Approved::Yes |
| Keyword | WBRKeyword::Hepatitis C, WBRKeyword::Liver transplant |
| Linked Question | Linked:: |
| Order in Linked Questions | LinkedOrder:: |