Acute liver injury induced by weight-loss herbal supplements

Figure 1 Liver biopsy showed extensive patchy areas of multilobular necrosis with only bile ducts remaining, extensive ductal metaplasia, severe lymphocytic and macrophages infiltration of portal tracts and lobular parenchyma and patchy plasma cell infiltrates. Histological changes were consistent with acute troxis necrosis and fulminant hepatitis. A: Liver lobules showing massive necrosis with only bile ducts remaining (hematoxiline and eosin stain × 52); B: Lymphocytic infiltration of portal tract and lobular parenchyma (hematoxiline and eosin stain × 130); C: Liver lobular necrosis with macrophages cleaning the debris (CD68 stain × 130); D: Ductal metaplasia. Lymphocytic infiltration in the sinusoids (CAM5.2 stain × 260); E: High power, lymphocytes destroying hepatocytes (CAM5.2 stain × 520); F: Lymphocyte “eating” hepatocytes in a liver parenchyma (troxis necrosis), arrow showing immunological synapses (Electron microscopy × 15000).

Figure 2 Liver biopsy was performed and showed periportal bridging fibrosis, ductal metaplasia, cholestasis, moderate intralobular lymphocytic infiltration, and troxis necrosis and apoptosis consistent with drug-induced hepatitis on top chronic liver disease. A: Liver showing periportal fibrosis and cholestasis (periodic acid-Schiff stain × 130); B: Portal tract showing ductal metaplasia and periportal fibrosis (AE1/AE3 stain × 260); C: Portal - portal bridging fibrosis (CAM5.2 stain × 52); D: Portal - portal bridging fibrosis (Reticulin stain × 52).

Figure 3 A liver biopsy revealed acute hepatitis characterized by hepatocellular injury, with periportal fibrosis, cholestasis, ductal metaplasia and diffuse intralobular and periportal troxis necrosis consistent with a drug-induced etiology. Intralobular lymphocytic infiltration. Arrow showing apoptosis of hepatocytes (hematoxiline and eosin stain × 260).