S2503 A Towering Case of Giant-Cell Hepatitis

INTRODUCTION: Giant-cell hepatitis (GCH) is a rare occurrence in adults, and is marked by the formation of large, multinucleated hepatocytes. It has been reported to occur due to a variety of insults to the liver, including drugs, viruses, and toxins. Despite the existence of numerous documented cases, its pathogenesis remains a mystery. We report a case of GCH in the setting of chronic alcohol use, treatment naïve hepatitis C, active herpes simplex virus type 1 (HSV-1), and autoimmune hepatitis (AIH). CASE DESCRIPTION/METHODS: A 51-year-old male with past medical history significant for chronic alcohol use, sober for 6 months, presented due to worsening jaundice and malaise. Prior to presentation, he had undergone an extensive outside hospital evaluation including MRCP that demonstrated diffuse hepatic steatosis with a mild prominent pancreatic head, but without pancreatic or common bile duct dilation, and transjugular liver biopsy which found marked lobular inflammation with numerous multinucleated giant hepatocytes and focal cholestasis, as well as marked bridging and peri-sinusoidal fibrosis. On presentation, the patient was found to have elevated liver function tests with ALT 469, AST 657, ALK Phos 169, and total bilirubin of 3.3 mg/dL. Further evaluation found that he was positive for hepatitis C genotype 1a (7,727 IU/mL), HSV-1 (IgG and IgM), an antinuclear antibody (ANA) of 1:2560 (homogenous), and weakly positive smooth muscle antibody (30 units). The patient was started on acyclovir for HSV-1 and glucocorticoid therapy for suspected AIH. His liver biopsy was stained for HSV-1 and was negative, so acyclovir was discontinued. His hospital course was complicated by acute kidney failure and worsening liver failure which ultimately resulted the patient undergoing deceased donor orthotopic liver transplantation (OLT). Final pathology on the recipient liver was consistent with post-infantile GCH, complicated by cirrhosis. DISCUSSION: Despite the first appearance of GCH in the literature in 1991, it remains largely a mystery [1]. Hepatitis C and AIH have been described in the literature as causes, but establishing a final diagnosis remains challenging and requires biopsy [2–3]. This case illustrates a biopsy confirmed cased of CGH due to a combination of precipitating causes of GCH including alcohol, hepatitis C confirmed by serology, and AIH. It also highlights the potential severity of GCH given the patient ultimately progressed to cirrhosis requiring OLT.Figure 1.: Histology demonstrating giant cell hepatitis with multinucleated giant cells.