title: Pathology case of the month. Altered mental status, alcohol abuse, and hyperammonemia. DIAGNOSIS: Mallory-Denk bodies (a.k.a. Mallory’s hyaline)–seen most commonly in alcoholic liver disease.
abstract: A 74-year-old woman with a past medical history of diabetes, hypertension, and alcohol abuse was brought to the emergency department and subsequently admitted to the intensive care unit with an altered mental status and weakness. Laboratories revealed acute renal failure (BUN 15 mg/dL, creatinine 2.5 mg/dL), elevated serum transaminase (AST of 83 IU/L), hyperammonemia (187 ug/dL), and marked normocytic anemia requiring transfusion of three units of packed red cells (hemoglobin 4.3 g/dL; hematocrit 13.1%). Blood ethanol level at the time of admission was less than 5 mg/dL, and full urine toxicology was negative. Alcohol abuse was reported to consist of, on average, "one pint of gin per day." Her hospital course was nine days and included complete inotropic blood pressure support and intubation. On the ninth day, she was declared dead, and authorization for an unrestricted autopsy was granted by the coroner. At autopsy, two liters of serous ascitic fluid was drained from the peritoneal cavity, and non-ruptured, distended varices were identified at the gastroesophageal junction. Additional findings included changes compatible with hypertensive cardiovascular disease, including hypertrophy of the interventricular cardiac septum and glomerulosclerosis along with renal atrophy. The liver weighed 1,300 grams (normal 1,475 gm±362) and was markedly discolored yellow-tan. Its parenchyma was more firm than usual. Representative microscopic sections from the decedent's liver are shown in the image below.
authors: Third-year Pathology Resident in the Department of Pathology at Louisiana State University School of Medicine in New Orleans.
authors: Theresa
authors: T
authors: Nuttli
authors: Associate Professor of Pathology and Residency Program Director in the Department of Pathology at Louisiana State University School of Medicine in New Orleans.
authors: Robin R
authors: RR
authors: McGoey
mesh_terms: D000368:Aged; D000437:Alcoholism / Q000097:blood / Q000150:complications / Q000473:pathology / Q000628:therapy; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D022124:Hyperammonemia / Q000097:blood / Q000209:etiology / Q000473:pathology / Q000628:therapy; D008108:Liver Diseases, Alcoholic / Q000097:blood / Q000209:etiology / Q000473:pathology / Q000628:therapy; D001523:Mental Disorders / Q000097:blood / Q000209:etiology / Q000473:pathology / Q000628:therapy