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接骨七厘片诱导自身免疫样肝炎1例报告
DOI: 10.12449/JCH260520
伦理学声明：本例报告已获得患者及其家属知情同意。
利益冲突声明：本文不存在任何利益冲突。
作者贡献声明：周云松负责采集病例资料，起草文章；赵琦对文章内容作批阅性审阅和指导；涂中琴和童平珍提供肝脏病理切片的知识内容；范光明提供肝脏影像学的知识内容。
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摘要: 药物诱导自身免疫样肝炎（DI-ALH）是药物性肝损伤的特殊表型之一，与固有型自身免疫性肝炎具有相似的免疫特征和肝组织学表现，因此二者有时难以鉴别诊断。本文报道1例经长期随访后诊断为DI-ALH的病例，并复习相关文献，以供临床医师参考。
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关键词:
- 化学性与药物性肝损伤 /
- 肝炎， 自身免疫性 /
- 接骨七厘片
Abstract: Drug-induced autoimmune-like hepatitis （DI-ALH） is one of the special phenotypes of drug-induced liver injury， and since it has similar autoimmune characteristics and liver histological manifestations as intrinsic autoimmune hepatitis， differential diagnosis of these two diseases may be difficult in some cases. This article reports a case diagnosed with DI-ALH after long-term follow-up and conducts a literature review to provide a reference for clinicians. -
注： a，T1加权像信号改变不明显；b，T2加权像示肝脏多发小囊肿；c，DWI像示肝右叶呈稍高信号，邻近肝包膜局限性皱缩。
图 1 上腹部磁共振成像结果
Figure 1. The magnetic resonance images of upper abdominal
注： a，切片内共20个完整及不完整汇管区，肝小叶结构紊乱（HE染色，×40）；b，肝细胞轻度至明显水肿，可见气球样变性肝细胞，少数嗜酸性变肝细胞及嗜酸性小体，少数糖原核肝细胞，肝细胞大泡、微泡脂肪变性（肝脂肪变性细胞<5%），无规律分布，可见点状、融合性及桥接坏死，少数巨细胞变肝细胞，可见玫瑰花结样肝细胞，部分肝细胞可见淤胆性及棕褐色色素颗粒；中央静脉偏位或缺失；汇管区较多淋巴细胞、浆细胞、少量中性粒细胞浸润，重度界面炎（HE染色，×200）；c，CD68大量表达，提示较多活化的肝巨噬细胞（DAB染色，×40）；d，CK19免疫组化阳性，提示轻-中度细胆管增生（DAB染色，×40）；e，桥接纤维化，局部假小叶形成趋势，中度窦周纤维化；汇管区不同程度扩大，纤维组织增生，可见桥接纤维化，局部假小叶形成趋势（马森染色，×40）；f，示肝板网状支架紊乱、灶性塌陷（网状纤维染色，×40）；g，电镜超微病理（×2 500）；h，电镜超微病理（×4 000）：肝细胞肿胀，核圆形，核膜光滑，粗面内质网轻微扩张；多数线粒体外形正常，少数线粒体肿胀，体积较大，外形不规则，内见结晶；肝细胞间隙未见增宽，部分肝细胞内可见脂滴；肝细胞内可见散在的淤胆性色素颗粒，区域性毛细胆管轻度扩张；肝窦内皮细胞肿胀，可见淋巴细胞、肝巨噬细胞、肝星状细胞；区域性肝细胞间及Disse间隙可见束状胶原纤维沉积；汇管区密集胶原纤维沉积伴淋巴细胞、浆细胞浸润，可见小胆管。HE染色，苏木精-伊红染色；DAB染色，3，3’-二氨基联苯胺染色。
图 2 经皮肝活组织检查结果
Figure 2. The result of liver biopsy
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