Case Discussion      A 70-year-old man was admitted due to general malaise, poor appetite and yellowish skin discoloration for 2 weeks.      This gentleman had been known to be an HBsAg carrier for 7 years. Follow-up liver tests in recent one year were within normal limits. He began to suffer from vertigo, unsteady gait, left facial palsy and progressive left hearing loss since 10 weeks before this entry. Head MRI disclosed a 2-cm tumor at left cerebellopontine angle. Craniotomy with tumor excision was done 8 weeks before entry. Histological examination of the tumor revealed neurolemmoma. Steroid therapy for 4 weeks was given since the day of operation. Initially, he was given with intravenous methylprednisolone 80 mg q6h for 2 days, 80 mg q12h for another 2 days. Then shifted to oral dexamethasone 2 mg tid for 12 days, 1 mg tid for 12 days, and then stopped. Two weeks after discontinuation of steroid, he began to suffer from general malaise, poor appetite and later yellowish discoloration of skin. He was admitted 2 weeks later.       On admission, his consciousness was clear. Skin was yellowish discolored and sclera icteric. Liver span over right mid-clavicular line was 9 cm. There was no abdominal shifting dullness or lower leg edema. Abdominal ultrasound demonstrated trivial ascites and gallbladder sludge. There was no dilatation of biliary tree. Blood tests showed AST 2686 U/L, total bilirubin 10.4 mg/dl. Hemogram showed white blood cell count 5080/μl, hemoglobin 10.8 g/dl, platelet count 109 K/μl, and prothrombin time 32.2 sec （control 12.1 sec）. Unfortunately, progressive drowsiness developed since the second hospitalization day. After a blood sampling for the measurement of HBV DNA, Lamivudine (200 mg/day) was prescribed empirically for the suspicion of HBV reactivation with hepatic failure. But his conciousness went downhill rapidly and relentlessly. He became semicomatous and then comatous within 2 days. His liver span shrank to 7 cm. Extremities became rigid and spastic initially with later flaccid. Mild pitting edema over lower legs was also noted.       Head CT showed no hemorrhage, edema or focal lesion in the brain. He was treated as fulminant hepatic failure. Oral Lactulose and parenteral Mannitol was given. He developed thereafter gastrointestinal bleeding as manifested by tarry stool passage and pneumonia as manifested by fever, leukocytosis and shown by chest roentgenograms. Proton pump inhibitor and antibiotics were given. His consciousness did not return and he expired 10 days after hospitalization. A necropsy of liver was performed. Liver histology revealed submassive necrosis of the liver and dense lymphocyte infiltration and ballooning and cholestasis in residual hepatocytes (Fig. 1 ). <Laboratory Results> 1. Viral DNA and serology HBV DNA: 969.7 pg/ml (normal <0.5 pg/ml) HBsAg: positive HBeAg: negative Anti-HBe: positive IgM anti-HBc: negative IgM anti-HAV: negative Anti-HCV: negative Anti-Delta: negative CMV antibody: negative EBV-VCA IgM: negative HSV antibody: negative 2. Hemogram Hospitali -zation day WBC K/μl Hb gm/dl Hct (%) Platelet K/μl Seg (%) PT/control (sec) PTT/control (sec) 1st 5.08 10.8 33 109 55.7 32.2/12.1 69.5/37.5 5th 5.3 9.8 32 101 70.9 29.1/12.3 55.4/37.3 9th 17.85 14.5 43 122 74 44.8/11.1 59.1/32 3. Blood chemistry Hospitali -zation day Alb (g/dl) T-bil (mg/dl) D-bil (mg/dl) AST (U/L) ALT (U/L) ALP (U/L) BUN (mg/dl) Cr. (mg/dl) NH3 (μ mol/L) 1st   10.4   2686     18.7 0.8 91 2nd 2.5 9.9 7.0 3500 1677 303       5th   12.5 7.9 567 544   11.4 0.8 32 9th   19.2 12.4 91 125   21.6 1.3 37 案例分析      本案例為一個B型肝炎帶原者，於接受腦部腫瘤手術之後使用類固醇。在停止使用類固醇後，發生肝功能異常及黃疸現象。超音波檢查並無膽道阻塞的現象，排除了膽道疾患造成的黃疸及肝功能異常。在高度懷疑B型肝炎急性惡化之下，立即使用Lamivudine治療。在排除其他急性肝炎的可能性後確定為B型肝炎急性惡化合併肝衰竭。不幸的是，雖然在Lamivudine治療之下，肝功能異常及黃疸持續惡化，併發一系列肝衰竭合併症，最後死亡。慢性B型肝炎急性惡化病人約2.4%會合併急性肝衰竭，此時抗病毒藥物為治療之首要考慮，並加上支持性療法以預防併發症之產生及進一步治療。若未能遏止肝衰竭的進行，則應考慮肝臟移植手術。 繼續教育考題 1. (E) Which description of neurolemmoma is WRONG? A Mostly arise from the eighth cranial nerve B Develop from Schwann cells of the nerve root C Correlated with type II neurofibromatosis D Surgical intervention is the first choice of treatment E All are correct 2. (D) What is the most likely cause of the conscious disturbance in this patient? A Gastrointestinal bleeding B Post-concussion syndrome C Infection with sepsis D Hepatic encephalopathy E None of above 3. (E) Initial differential diagnosis of the hepatitis in this patient should include A HBV reactivation B HCV superinfection C HDV superinfection D CMV infection E All of above 4. (C) Which is WRONG about Lamivudine? A It is a nucleotide analogue, originally used to treat HIV infection B It can also inhibit the replication of HBV, including pre-core mutant HBV C It is more effective when there is less hepatitis activity D Long term usage will lead to emergence of resistant strain and failure of therapy E All are correct 5. (C) What is the purpose to use steroid in this patient? A Treatment for cerebellopontine angle tumor B Priming for lamivudine usage C Prevent IICP D Immunosuppression E All are correct 6. (E) Which is NOT the indication for liver biopsy? A Determine the cause of abnormal hepatic biochemical tests B Grading and staging of chronic hepatitis C Evaluate efficacy of treatment regimens D Evaluation of unexplained jaundice, acute hepatitis of unclear etiology, and hepatomegaly E All are correct 7. (A) The most common cause of fulminant hepatic failure in Taiwan is A Hepatotropic viral infection B Herbs C Wilson's disease D Acetaminophen E None of above 8. (E) Which is NOT the complication of hepatic failure? A Hepatic encephalopathy B Ascites C Hypoglycemia D Cerebral edema E All are complications of hepatic failure 9. (B) Which is WRONG about the steroid usage in HBV carriers? A Steroid withdrawal may induce HBV flare-up B Steroid must be used before lamivudine treatment C Steroid could stimulate HBV gene expression D Steroid may cause other viral, bacterial or fungal infection E All are correct 10. (C) For patients carrying HBV, which is correct? A Chemotherapy or immunosuppressive agents and steroid usage will inevitably lead to reactivation of HBV B Before chemotherapy, immunosuppressant, and steroid usage, antiviral agents (such as Lamivudine) should be prescribed for prophylaxis of HBV flare up C Liver tests should be monitored closely during and after usage of steroid or chemotherapeutic and immunosuppressive agents D If hepatitis occurred when chemotherapy or immunosuppressive agents were used without combining usage of antiviral agents, the chemotherapy or immunosuppressive agents should be discontinued immediately and antiviral agents started E All are correct

答案解說 答案解說: 1. (E) 2. (D) There are no obvious symptoms and signs of GI bleeding or infection in our patient. Postconcussion syndrome is a syndrome of fatigue, dizziness, headache and difficulty in concentration after mild injury. Also, there is a period of time between the head injury and the conscious change. So, conscious disturbance from the head injury is less likely. 3. (E) 4. (C) Lamivudine is more effective when pre-treatment hepatitis activity is higher, for example, ALT value > 5 times of upper normal limit. 5. (C) 6. (E) 7. (A) In the western countries, acetaminophen is the most common cause of acute hepatic failure. (J. Gastroenterol Hepatol 2000; 15:480-488) In Taiwan, although acetaminophen is increasingly used, the most common cause of acute hepatic failure is still hepatotropic virus. Most of them are HBV—related. 8. (E) 9. (B) Steroid was used for priming in studies of lamivudine treatment. However, that carries a risk of hepatic failure and the prior steroid usage is not a standard treatment regimen for chronic hepatitis B. 10. (C) The relationship between chemotherapy, immunosuppression and hepatits is under investigation. Also, there is no consensus about the prophylactic usage of antiviral agents and the standard management of HBV flare-up after chemotherapy or immunosuppression. Top of Page