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Old 05-21-2013
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Liver Gastroenterology Q18

A 34-year-old woman is evaluated for fatigue, malaise, arthralgias, and a 10-lb weight loss over the past 6–8 weeks. She has no past medical history. Since feeling poorly, she has taken approximately one or two tablets of acetaminophen 500 mg daily. On physical examination, her temperature is 100.2°F, respiratory rate is 18 breaths/ min, blood pressure is 100/48 mmHg, heart rate is 92 beats/min, and oxygen saturation is 96% on room air.
She has scleral icterus. Her liver edge is palpable 3 cm below the right costal margin. It is smooth and tender.
The spleen is not enlarged. She has mild synovitis in the small joints of her hands. Her AST is 542 U/L, ALT is 657 U/L, alkaline phosphatase is 102 U/L, total bilirubin is 5.3 mg/dL, and direct bilirubin is 4.8 mg/dL. Which of the following tests would be LEAST likely to be positive in this diagnosis?
A. Antinuclear antibodies in a homogeneous pattern
B. Anti-liver/kidney microsomal antibodies
C. Antimitochondrial antibodies
D. Hypergammaglobulinemia
E. Rheumatoid factor
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Old 05-21-2013
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Quote:
Originally Posted by cingulate.gyrus View Post
A 34-year-old woman is evaluated for fatigue, malaise, arthralgias, and a 10-lb weight loss over the past 6–8 weeks. She has no past medical history. Since feeling poorly, she has taken approximately one or two tablets of acetaminophen 500 mg daily. On physical examination, her temperature is 100.2°F, respiratory rate is 18 breaths/ min, blood pressure is 100/48 mmHg, heart rate is 92 beats/min, and oxygen saturation is 96% on room air.
She has scleral icterus. Her liver edge is palpable 3 cm below the right costal margin. It is smooth and tender.
The spleen is not enlarged. She has mild synovitis in the small joints of her hands. Her AST is 542 U/L, ALT is 657 U/L, alkaline phosphatase is 102 U/L, total bilirubin is 5.3 mg/dL, and direct bilirubin is 4.8 mg/dL. Which of the following tests would be LEAST likely to be positive in this diagnosis?
A. Antinuclear antibodies in a homogeneous pattern
B. Anti-liver/kidney microsomal antibodies
C. Antimitochondrial antibodies
D. Hypergammaglobulinemia
E. Rheumatoid factor
ANAs can be positive in Primary Sclerosing Cholangitis and Primary Biliary cirrhosis.. which are differentials in this case..
D will be increased in cases of Hepatitis C.. which could easily explain the ALT greater than AST..
I have never heard of rheumatoid factor being increased in liver disease..
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Old 05-26-2013
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The answer is C.Antimitochondrial antibodies

Three types of autoimmune hepatitis have been identified based on clinical and laboratory characteristics. Type I autoimmune hepatitis is a disor-der typically seen in young women. The clinical characteristics can be variable from those of chronic hepatitis to fulminant hepatic failure, and many of the features are difficult to distinguish from other causes of chronic hepatitis. In some individuals, extrahepatic mani-festations including fatigue, malaise, weight loss, anorexia, and arthralgias can be quite prominent. Liver enzymes are elevated but may not correlate with the clinical severity of disease. In more severe cases, elevations in serum bilirubin between 3 and 10 mg/dL can be seen. Hypoalbuminemia occurs in advanced disease, and hypergammaglobulinemia (>2.5 g/dL) is very common. The circulating antibody profile in autoimmune hepatitis depends to some extent on the type of hepatitis. Antinuclear antibodies are positive in a homogeneous staining pattern almost invariably in the disease, and rheumatoid factor is also common. Perinuclear antineutrophilic cytoplasmic antibody may be positive, but in an atypical fashion. Anti–smooth muscle antibodies and anti–liver/kidney microsomal antibodies are frequently seen, but these are nonspecific as other causes of chronic hepa-titis can lead to positivity of these enzymes. Because of the lack of a specific autoimmune profile, the diagnostic criteria for autoimmune hepatitis incorporate a variety of clinical and laboratory features. Specific features that argue against this diagnosis include promi-nent alkaline phosphatase elevation, presence of mitochondrial antibodies, markers of viral hepatitis, history of hepatotoxic drugs or excess alcohol intake, and histologic evidence of bile duct injury or atypical biopsy features including excess hepatic iron, fatty infiltration, and viral inclusions. Antimitochondrial antibodies are typically seen in primary biliary cirrhosis.


Last edited by cingulate.gyrus; 05-26-2013 at 04:05 AM.
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