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Acute perihepatitis has classically been associated with chlamydia and gonorrhea infections infection blood pressure order generic goutichine, but also seen secondary to candidiasis [67] antibiotics for uti during pregnancy buy 0.5mg goutichine fast delivery. The associated pain is usually sharp infection process goutichine 0.5 mg with mastercard, pleuritic antibiotics for acne ireland order goutichine on line amex, and located in the right upper quadrant. The diagnosis may be established clinically, but definite diagnosis is confirmed by laparoscopy. Spirochetal infections Leptospirosis Leptospirosis is a zoonotic infection with broad geographic distribution due to its large spectrum of mammalian hosts (mainly cattle and rats) that harbor and excrete the spirochete from renal tubules. It is endemic in humid, tropical and subtropical developing countries, in particular in Asia Pacific [77,78]. The manifestations are protean (can resemble those caused by dengue, hantavirus, Zika, malaria, and influenza), often subclinical, and classically described as a biphasic illness, with anicteric and icterohemorrhagic phases. Additional second-phase manifestations include fever, headache, aseptic meningitis, and pulmonary involvement. Abdominal pain in the right upper quadrant can mimic acute cholecystitis and pancreatitis. Transmission can occur through the placenta or breast milk ingestion, resulting in intrauterine or neonatal infection, respectively. Leptospirosis is associated with increased risk of spontaneous abortion, stillbirth, and congenital defects [82]. Pyogenic liver abscess associated with Campylobacter curvus bacteremia has been described [73]. Catscratch disease Bartonella henselae is the etiologic agent of catscratch disease, which typically runs a self-limited course characterized by lymphadenopathy in children who were infected from the bites of infected cats or fleas. Catscratch disease has been reported in solid organ recipients with diverse manifestations including disseminated disease [76]. Dark-ground microscopic examination of plasma has been found to be a simple and rapid form of early diagnosis when hepatorenal involvement is present. Liver biopsy findings show cholestasis, increased mitotic activity, and mild periportal hepatitis. Finally, immunohistochemistry stain of leptospirosis antigen can assist in diagnosis [83]. A Cochrane database review and a systematic review and meta-analysis suggested limited or no impact of antibiotics on mortality [84,85]. Use of high-dose corticosteroids in severe leptospirosis has not shown robust evidence to support it [86]. The pathologic findings of hepatic syphilis include lymphocytic and neutrophilic infiltrates in the portal tracts, while pericholangiolar inflammation has also been described. Gummas are fibrotic lesions with or without granulomatous inflammation and central necrosis [90]. Additional laboratory studies of the syphilitic hepatitis of secondary stage disease include a hemagglutination test for T. Treatment with penicillin usually results in symptomatic as well as well biochemical resolution of syphilitic hepatitis. Syphilis Syphilis is a multisystemic disease caused by the spirochete Treponema pallidum. Liver involvement is rare, but has been reported in early syphilis (primary or secondary). Gummas of the liver characterize tertiary syphilis and may resemble metastatic disease or cirrhosis because of the nodular configuration of the liver (hepar Lyme disease the most common reportable vector-borne disease in the United States is caused by the spirochete Borrelia burgdorferi and is transmitted to humans by the bite of infected ticks (Ixodes). Lyme disease is endemic in the northeast United States, but is increasingly being recognized throughout the country [91]. Histologic examination shows portal inflammation, ballooning of hepatocytes, and sinusoidal mononuclear and neutrophil cell infiltration [94]. Chapter 8: Hepatic Manifestations of Systemic Disorders 225 Rickettsial infection Q fever Coxiella burnetti is the causative organism of Q fever. This disease is of worldwide distribution, except for French Polynesia and New Zealand where, perhaps related to very strict importation criteria for animal and plants, extensive serology testing of the reservoirs has been negative [96,97]. Inhalation of contaminated aerosols and dusts from infected animal products as well as transfusions, and sexual and percutaneous contact are the various routes of infection [98,99]. The classical presentation is of a febrile illness with flu-like symptoms, pneumonia, and mildly elevated liver enzymes with hepatomegaly [99]. Additional symptoms can include endocarditis, vascular and musculoskeletal infections, as well as neurological involvement [98]. Presentation may vary geographically, as pneumonia is reportedly more common in eastern Canada while hepatitis is more common in southern Spain [100]. Infection during pregnancy is less symptomatic and implies a heightened risk of miscarriage, growth retardation, fetal malformations, and premature birth [98].
Immunostaining for viral antigens in different types of viral hepatitis is extensively used for investigational purposes and antibiotic resistant gonorrhea 2015 cheap goutichine 0.5mg free shipping, to a lesser extent bacteria growth temperature buy goutichine 0.5mg online, for diagnosis virus 68 colorado cheap goutichine line. Hepatitis D virus can also be identified in routinely processed tissue bacteria filter order goutichine without prescription, but antibodies are more difficult to obtain. Hepatitis A, C, and E viruses can only be reliably identified in frozen sections, and staining for these is generally limited to research settings. Electron microscopy Transmission electron microscopy Transmission electron microscopy has many investigational applications but a limited number of diagnostic ones [6]. Its greatest value is in the interpretation of biopsy specimens from patients with known or suspected metabolic disorders, and it can also be helpful in druginduced and cholestatic diseases and in some infections. Scanning electron microscopy Scanning electron microscopy has also proved more useful for investigation than for diagnosis. The diagnostic applications of this technique are largely limited to particulate material, especially when X-ray spectrophotometry (also called electron probe analysis) is combined with scanning electron microscopy [7]. Using this technique, the elements that are present in particulate material, such as talc, Thorotrast, silicone, silica, titanium, gold, and barium sulfate can be positively identified. Polarizing microscopy this is useful in identifying birefringent crystals of talc. The remnants of previous surgery, such as suture material, talc, or starch from glove powder left on the surface of the liver are also birefringent in polarized light, as is silica in multiorgan silicosis [11]. Type I collagen has a silvery birefringence, and amyloid has a characteristic apple green birefringence when sections stained with Congo red are examined by polarizing microscopy. Formalin pigment (typically in blood vessels) and both malarial and schistosomal pigments (in reticuloendothelial cells) are brown to black deposits of acid hematin and are birefringent under polarized light. Needle-like uroporphyrin crystals in liver cells can sometimes be visualized by polarizing microscopy of unstained frozen or paraffin sections in porphyria cutanea tarda [12]. Red birefringent Maltese crosses and amorphous materials are characteristic of protoporphyrin accumulation in canaliculi or Kupffer cells in erythropoietic protoporphyria. Drug-induced injury causes changes in many organelles of the liver depending on the drug, duration of use, and other factors. Megamitochondria, sometimes assuming monstrous forms, are considered typical of drug reactions, while lysosomal phospholipidosis is highly typical of several drugs. Subtle manifestations of cholestasis due to a variety of causes can be seen ultrastructurally before becoming recognizable by light microscopy. Among infectious agents, viral particles can be visualized directly in herpes Chapter 6: Hepatic Histopathology 141 Figure 6. Morphologic patterns of injury Acute necroinflammatory disease (acute hepatitis) Acute necroinflammatory disease is typically seen in cases of acute infection with the hepatitis viruses, but identical injury may occur with hepatitis-like reactions to a number of therapeutic drugs (see Chapter 27). Hepatocellular injury, leading to cell death, is the predominant morphologic feature of acute necroinflammatory diseases, although the term necroinflammatory has become something of a misnomer in view of recent advances in pathobiology. The term necrosis, previously used for all forms of cell death, is now applied more selectively to certain forms of cell death. Many of the injured and dying cells seen in the various forms of hepatitis are actually in the process of apoptosis, while the "inflammatory" component is at times the effector of apoptosis and at times the response to the hepatocellular injury. Nevertheless, for the purposes of this discussion, the term necroinflammatory will be maintained. Several basic lesions are seen in various forms of necroinflammatory injury: Figure 6. The cytoplasm of the liver cell develops protuberances that separate and are released into the spaces of Disse and sinusoids. The larger cell fragments, which may contain parts of the nucleus, have been termed apoptotic, acidophilic, or hyaline bodies (Figs 6. The apoptotic bodies are quickly phagocytosed by Kupffer cells where they undergo degradation and are reduced to residual bodies. Affected cells have an indistinct cell membrane and the cytoplasm is rarefied (Figs 6. The ballooned hepatocytes eventually undergo lysis, with disappearance or "dropping out. The cell outline may be maintained for some time, but this is eventually lost as the tissue becomes amorphous. This change is typical of anoxic injury, although it may be seen in some forms of necroinflammatory injury. Sinusoidal macrophages are normally inconspicuous, but in response to liver cell death these enlarge as they perform their phagocytic function. They can be recognized by the presence of cytoplasmic light brown, finely granular lipofuscin presumed to be phagocytosed from necrotic hepatocytes (Figs 6. Acute necroinflammatory patterns Acute hepatitis "Classic" acute hepatitis, typical of the common forms of acute viral hepatitis, is characterized by panacinar Chapter 6: Hepatic Histopathology 143 Figure 6. A cluster of inflammatory cells ("focal necrosis") in the center of the field shows the position where a hepatocyte has disappeared from the tissue (arrow). Clusters of hypertrophied Kupffer cells (K) are present at sites of liver cell dropout. These are seen throughout the acinus in various combinations, and not all hepatocytes in a given acinus are Figure 6. The cytoplasm of the necrotic cells is eosinophilic and granular, and the nuclei have disappeared. Features of regeneration are invariably present, and there is typically an inflammatory response consisting of hypertrophied Kupffer cells and lymphocytes. The portal areas in typical acute hepatitis are usually infiltrated with inflammatory cells.
The onset of disease is never after delivery antibiotics zone diameter generic 0.5 mg goutichine free shipping, but the diagnosis may be made after delivery antibiotic resistance in jamaica buy 0.5mg goutichine. The most frequent initial symptoms are nausea or vomiting bacteria reproduction process purchase goutichine 0.5 mg mastercard, abdominal pain (especially epigastric) virus que esta en santo domingo purchase goutichine 0.5mg with amex, anorexia, and jaundice. About half of affected patients have high blood pressure or proteinuria, which are the main symptoms of preeclampsia [80]. Liver dysfunction can progress to acute hepatic failure manifest by encephalopathy, coagulopathy, and hypoglycemia. As the disease advances, renal dysfunction is typical and severe pancreatitis can occur [78]. The serum aminotransferase levels are raised, but usually the level is not as high as in acute viral hepatitis. In severe cases, the prothrombin time is increased and the fibrinogen level decreased. These coagulation disorders are caused by hepatic insufficiency, disseminated intravascular coagulation, or both. Thrombocytopenia may be the most striking laboratory feature and normalizes spontaneously after delivery. To help guide early diagnosis, the "Swansea criteria" based on symptoms and laboratory derangements were proposed in 2002 and validated in population-based cohorts [80] (Box 9. In clinical practice, these complementary examinations should not delay delivery, particularly in severe cases, which can usually be diagnosed on clinical grounds with routine biologic data. The maternal prognosis is currently greatly improved, and maternal mortality is about 10% or less worldwide [72,82,83]. This improvement is related principally to early delivery, to advances in intensive care support for patients with severe forms, and also to the detection of patients with less severe forms. Follow-up should be both clinical and biologic (liver function tests, tests for uricemia, and platelet counts twice monthly during the third trimester). Early delivery has also resulted in an improved fetal prognosis, and the final outcome for infants delivered alive is usually considered to be good. However, in view of the possibility of congenital enzyme deficiency involving intramitochondrial -oxidation of fatty acids, these infants should be closely followed from birth (see later). In affected families, a prenatal diagnosis based on sampling of chorionic villi has proved both feasible and accurate [93]. These findings suggest that a deficiency in the -oxidation enzyme in the fetus may spill unmetabolized long-chain fatty acids into the maternal circulation, leading to maternal hepatic steatosis if the mother is in the intermediate range for the deficiency [89]. If delivery is delayed complications such as hepatic failure, hemorrhage, and intrauterine death may develop. The choice of the route of delivery remains the decision of the obstetrician and must be appropriate for the individual clinical situation. For patients with severe disease, coagulation disorders, especially thrombocytopenia, are common and should be corrected. The blood sugar levels should be monitored and hypoglycemia treated by a continuous intravenous infusion of glucose. Patients with fulminant hepatic failure are best managed in an intensive care unit before and after delivery. If the hepatic dysfunction does not rapidly improve postpartum, evaluation for liver transplantation should commence efficiently [72,94]. Intercurrent liver disease in pregnancy Pregnant women remain susceptible to diseases that can affect the general population. Some disorders, such as hepatitis E, can take a fulminant course in pregnant women. Furthermore, pregnancy predisposes a woman to the development of liver diseases such as cholelithiasis. Acute viral hepatitis the response of a pregnant woman to acute infection with the viruses that cause hepatitis varies depending on the type of virus. Hepatitis A Pregnant women who contract hepatitis A are not at increased risk of severe disease from this infection [95], although the risk for premature labor may be increased in women who are seriously ill during the third trimester [96,97]. Hepatitis B In patients with documented acute hepatitis B, pregnancy is not associated with increased mortality or teratogenicity. Women exposed to hepatitis B during gestation may be vaccinated without any reported increase in congenital anomalies. Biliary tract disease and pancreatitis Pregnancy decreases gallbladder motility and increases the lithogenicity of bile. Pregnancy has long been considered a risk factor for the development of gallstones; epidemiologic studies confirm an association with an increased risk for gallstones, but only for a 5-year period after pregnancy. Ultrasonographic studies show that gallstones and biliary sludge may accumulate throughout gestation and then resolve with a return to nonpregnant physiology [110,111]. In a prospective study of 3254 women, the cumulative incidence of new sludge, new stones, or progression of baseline sludge to stones was 10. Similar to nonpregnant individuals, biliary colic can often be managed conservatively. Women who fail conservative management should be considered for surgical interventions. On retrospective review, 26% of nearly 37 000 pregnant women hospitalized with biliary track disease underwent cholecystectomy.
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