Drug Induced Ductopenia

History May 2004: 60y/o WM after 9 months of fatigue, night sweating, weight loss, hoarseness and cough: Nodular sclerosing Hodgkin’s Disease May 2004: 3 weeks of jaundice itching acholic stools

Medications: Celexa for 5 years Bextra for 5 days in the last month ASA Acetaminophen Lipitor ROS 18 months ago transient episode of skin excoriation and pruritus of the pubis and lower abdomen (tx as scabies) PMH: Subdural hematoma secondary to trauma ’97 Hypercholesterolemia Social: No smoking, no drugs 2 drinks/day (vodka or gin) Retired radiologist Family Hx: Wilson disease: cousin

Physical Examination 130/80 90x’ 12x’ 97.0F AOT3, deeply jaundice, no asterixis No jvd, small cervical adenopathy Reg S1S2, no gmr; CTAB BS+, ng/nt, no hsm, no ascites LE no edema

Laboratories 11.4 13.7 259 N 89% 37 L 3% PT 12.3 sec Glucose 110 PTT 23.2 sec Creatinine 1.2 LDH 605 AST 164 Ammonia 25 ALT 471 AMA neg Alk. Phosp. 689 ANA neg Total Bili. 18.1 Total Prot. 7.4 Albumin 3.6

Ultrasound: normal liver, no intra- or extrahepatic biliary dilatation CT: multiple mediastinal LAD, no intrabdominal abnormalities Normal MRCP

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Biopsy 5/14/04 No evidence of Hodgkin’s disease in the liver Moderate cholestasis Mild inflammation of the biliary spaces Paucity of bile ducts

Management Given ursodiol, cholestyramine and diphenidramine Improvement in ALKP from 689 to 371; Tbil from 14.5 to 10.5 Given MOPP (meclorethamine, procarbazine and prednisone; not given oncovin–vincristine) Later in his course added fat-soluble vitamins and biphosphonates

Ursodiol and MOPP (CTX) cholestyramine LAB 5/14 5/18 6/23 7/6 8/17 8/24 10/5 11/2 AST 222 164 135 114 115 86 51 56 ALT 586 471 200 145 116 79 54 ALK 1018 689 371 508 411 378 287 316 Tbil 15.8 14.5 10.5 13.9 7.8 1.5 0.9 Dbil 6.8 TP 7.7 7.4 Alb 3.8 3.6 Plt 384 259 266 PT 12.3 13.1 INR 0.91 1.05

Biopsy 10/26/04 (5 months later with biochemical resolution) Absence of bile ducts Chronic cholestasis Acute inflammatory response Portal fibrosis, without any bridging fibrosis