1. Drug Induced Ductopenia

2. 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

3. 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

4. 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

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

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

7. ?

8. 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

14. 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

15. 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

16. 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