A 67-year-old Korean female was admitted to our hospital because of intermittent fever for 2 months.
Four years before admission, she had visited a hospital because of fever and abdominal pain, and cholecystectomy was done due to acute calculous cholecystitis.
The fever was persistent and she had taken oriental herb medicine, thereafter, she had been in excellent health until 2 months earlier, when diabetes mellitus developed which was treated by oral hypoglycemic agent. In spite of enthusiastic management in the private clinic, fever developed again and was persistent.
The patient was a housewife, non-smoker and did not drink at all. There was no history of pulmonary tuberculosis. She complained of general weakness, fatigue, fever, weight loss (2.5 kilograms over 2 months) but denied cough, dyspnea, abdominal pain, nausea, vomiting, hemoptysis, frequent voiding and bladder or bowei dysfunction. The body temperature was 37.5 C, the pulse rate was 100/min, the respiration rate was 18/min and the blood pressure was 110/60 mmHg. On physical examination, she was pale and chronically ill-looking with alert mental state. She had pale conjunctiva and dehydrated tongue, and lymph nodes were impalpable. The lung, heart and abdomen were normal except for post-operative abdominal scar on the right upper quadrant.
The hemoglobin was 10.5 g/dl and the hematocrit 31.4%. The white cell count was 6,700/mm3, with 77.9% neutrophils, 0.9% lymphocyte, 6.9% monocytes and 2.3% eosinophils. The platelet count was 206,000/mm3. The erythrocyte sedimentation rate was 49 mm/hr. The aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were 13.6 and 9.0 IU/L, the alkaline phosphatase 71.2 IU/L, the total protein and albumin 6.1 and 3.3 g/dl, the direct bilirubin 0.2 mg/dl, the blood urea nitrogen and creatinine 5.9 and 0.5 mg/dl, the total cholesterol 134.1 mg/dl and total calcium was 7.6 mg/dl. The urine was normal. The alphafeto protein was below 5 ng/ml and the carcinoembryonic antigen was 1.44 ng/ml.
The thyroid function test was normal. The angiotensin converting enzyme was 23.1 U/ml (normal: 8-52U/ml). The brucella antibody was negative. The anti-mitochondrial antibody was negative. The sputum smear and culture for mycobacteria and fungus were negative. The chest X-ray showed a fibrosteak density in the right upper lobe and increased interstitial marking in both lungs. This finding was suggestive of inactive pulmonary tuberculosis (Fig. 1). The abdominal CT (computerized tomography) showed mildly dilated both intrahepatic ducts without internal calcific density and the common bile duct was not dilated (Fig. 2). The bone marrow biopsy showed normocelluarity (about 30% cellularity) with polymorphous cellular population and adequate megakaryocytes. The culture of bone marrow grew neither bacterium nor fungus. The needle biopsy of the liver showed relatively intact lobular architecture and hepatic cord arrangement and the portal area was some-what widened by infiltrated inflammatory cells and fibrosis, but the limiting plate was intact. There were a focal hepatocytic necrosis, perivenular cholestasis and a few ill-defined aggregates of epitheloid cells. No acid-fast bacillus was found (Fig. 3).
The antituberculosis medication was prescribed for 2 weeks as a therapeutic trial. Even after that, the temperature was 38.7 C. Thereafter, we prescribed prednisolone 1 mg/kg under the diagnosis of idiopathic granulomatous hepatitis.