Liver related but not transplant issues at this point

[RamblingSeminarian]

I wonder if you might have some insight into a liver issue that I have been experiencing.  I'm 26 years old now.  In April 2006 I contracted Hepatitis A, had about 2 weeks where I was really sick then gradually got better and regained my stamina.  My LFTs were very slow to return to normal.  At the end of that summer I started getting repeated sinus infections, then started intermittantly wheezing.  I moved across the country to go to graduate school in August 2006.  When my new doctor took blood for labs, my liver enzymes were again elevated, and a Hep panel in Oct 2006 still showed positive for Hep A, Ultrasound at that point looked good and all the enlargment I had in my liver and spleen had gone away.  My asthma/allergy problems continued to worsen, and I was finally diagnosed with Churg Strauss Syndrome, I have never been off steroids since then.  My liver is involved in the CSS, with areas of necrotizing granulomas found on biopsy.  Last december, my gallbladder decided to stop functioning properly (ejection fraction of only 8%) and so it was laproscopically removed Dec 19.  I had LFTs and another Hep panel at that point and everything was okay except a slight elevation in my AST, Hep panel was negative.  Since then I've been tried on methotrexate in order to reduce my prednisone dose, but that made my liver enzymes skyrocket and I was quickly taken off of it. Bloodwork 3 weeks ago once again showed elevated LFTs and a Positive Hep A result.  My doctor thinks that I was never able to produce the antibodies against the Hep A and that my negative reading in december was an issue of lab range differences.  If that's the case, would the liver be able to produce them while the immune system is being suppressed?  Is there any medications that can help it.  It's very frustrating to watch my breathing deteriorate and not be able to do anything about it because of the liver.  I would appreciate any insight you have.

[Thomas D Schiano, MD]

yours is a very enigmatic case.  Churg-strauss is not a very common diagnosis so i would definitely make sure that the diagnosis has been confirmed.  liver involvement is exceedingly rare.  the granulomas may be due to a secondary infection related to the steroids and not directly the churg-strauss  Churg-strauss and other types of vasculitis can cause acalculous cholecystitis and prompt the need for cholecystectomy.  While on prednisone you are immunosuppressed which might impede the production of protective or diagnostic hepatitis antibodies. how about medications such cellcept or azathioprine as steroid-sparing agents?

i hope this is helpful

[RamblingSeminarian]

You hit the nail on the head with the acalculous cholecystitis!  Late in October I began having pain in the gallbladder region, though ultrasounds consistently said no stones present.  I had a HIDA scan in November which showed my ejection fraction to be 8%...my gallbladder was removed in December.  The Churg Strauss has been confirmed not only by just the symptoms, but also from skin, liver and lung biopsies and also have "suspected granulomas" in my upper small intestine based on an ERCP.  We tried using Methotrexate a few months ago, but my liver enzymes skyrocketed and I developed acute pancreatitis (they have never clearly found the cause of the pancreatitis, whether it was medication-induced, or part of the disease).  My liver enzymes continue to remain elevated and I feel quite similar to how I felt when I first had Hep A, except that I'm not experiencing that nausea/vomiting....instead I just have the fatigue and URQ pain.  My doctors are leary about trying cellcept or imuran because of my liver.  Cytoxin has been mentioned, but that too seems to be hard on the liver.

[Thomas D Schiano, MD]

cellcept causes no liver problems whatsoever and although imuran may, it is a very rare cause of hepatotoxicity.  methotrexate and being on steroids long-term is not the answer. Has Crohn's disease been ruled out entirely?

[RamblingSeminarian]

I've never heard them mention Crohn's disease at all.  The digestive problems/liver issues were never an issue until 2006 when I got Hep A, the only problem I had prior to that was difficulty digesting most meats.  I'm currently mostly just on steroids and medications to help my breathing:

Prednisone
Qvar
Foradil
Ranitidine
Albuterol as needed

The methotrexate was stopped immediately when I went into the hospital with pancreatitis and increased liver enzymes, and there are no plans to restart that.

[Thomas D Schiano, MD]

i agree with not using methotrexate.