Clinicopathology conferences: Inflammation-induced cholestasis

Intrahepatic cholestasis may arise from many sources, and it therefore presents a particular challenge when it develops in the seriously ill patient.A 54-year-old patient with a myeloproliferative disorder is presented, who developed jaundice in the setting of a severe decubital infection, polypharmacology, multiple blood transfusions for anemia, renal insufficiency, parenteral alimentation, and a history of long-standing alcohol abuse, a positive purified protein derivative, and recent biopsy-proven laryngeal squamous cell carcinoma.The thesis is advanced that many insults may cause local and systemic activation of the inflammatory cytokine system, and that these proinflammatory events are potent inducers of intrahepatic cholestasis. CASE HISTORYA 54-year-old male civil engineer was admitted with a 1-month history of headaches, fever, sore throat, sinusitis, myalgias, and general malaise.He had a long history of heavy drinking (up to 0.5 pints of liquor per day) and heavy smoking (Ͼ100 pack years), extending up to the time of his admission.He was known to be purified protein derivativepositive.On admission, he was a well-developed 83-kg white male with hoarseness, a temperature of 100°F, orthostatic hypotension, and 2ϩ pitting edema to his mid-calves.There was no hepatosplenomegaly.A chest roentgenogram showed mild chronic obstructive pulmonary disease with no evidence of active tuberculosis.His hematocrit was 35.7%, and the peripheral white blood cell count was 22,000/mm 3 with 2% myeloblasts.The erythrocyte sedimentation rate was 126 mm/h.His serum glutamate pyruvate transaminase was 25 IU/L (normal, 5-40 IU/L), serum glutamate oxaloacetate transaminase was 13 IU/L (normal, 5-40 IU/L), serum alkaline phosphatase was 95 IU/L (normal, 35-125 IU/L), serum lactate dehydrogenase was 230 IU/L (normal, 20-200 IU/L), serum total bilirubin was 0.5 mg/dL (normal, Ͻ1.0 mg/dL), and serum albumin was 2.3 g/dL (normal, 3.5-5.5 g/dL).Viral serologies were negative for hepatitis A and hepatitis B (this case antedated hepatitis C testing).