CPC CLINICOPATHOLOGICAL CONFERENCE REPORT


https://doi.org/10.5005/jp-journals-10028-1656
Journal of Postgraduate Medicine, Education and Research
Volume 58 | Issue 01 | Year 2024

Indian Childhood Cirrhosis: A Disappearing Evil


Nishtha Ahuja1, Suvradeep Mitra2, Uma Nahar Saikia3, Arun Bansal4, Sadhna Lal5, Sanjay Jain6, Savita Attri7

1Department of Telemedicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

2,3Department of Histopathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

4Department of Paediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

5Department of Paediatrics; Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

6Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

7Department of Biochemistry, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Corresponding Author: Uma Nahar Saikia, Department of Histopathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, Phone: +91 9876288554, e-mail: umasaikia@gmail.com

How to cite this article: Ahuja N, Mitra S, Saikia UN, et al. Indian Childhood Cirrhosis: A Disappearing Evil. J Postgrad Med Edu Res 2024;58(1):43–52.

Source of support: Nil

Conflict of interest: None

CASE DESCRIPTION

A 12-month-old girl child presented with fever for 20 days, abdominal distention for 10 days, and developed significant jaundice later, followed by generalized swelling and vomiting for 5 days. This illness began with high-grade fever, which was sporadic, and required treatment with paracetamol. She then developed abdominal distention, which started from the upper abdomen and eventually spread to the whole belly. Since the last 2 days, there has been a sudden increase in abdominal distention. She also had yellowish discoloration of her eyes, which gradually spread to her palms and soles. The jaundice worsened over the last 2 days prior to admission with dark urine and staining of diapers. The swelling first began in the periorbital region and spread to the palm and soles. There was a history of intermittent pale-colored stools. There was also history of mild pruritus since 5 months of age. A significant history of food being cooked in copper or brass vessels since 6 months of age was present, which was corroborated by the parents multiple times. There was no history of cola or red-colored urine. No history of difficulty in breathing, altered sensorium, or bleeding from any site was present. A history of mefenamic acid and intake of alternative medicines was noted in the last 1 month. The past history was insignificant. She was the only child in the family, born at term 3.2 kg, immunized as per the schedule, with no history of neonatal jaundice or seizures. For the present illness, a week back, she was admitted to a private hospital where she received intravenous (IV) meropenem and amikacin for 7 days.

LAB INVESTIGATIONS

Investigations performed before coming to Post Graduate Institute (PGI)—the hemogram showed hemoglobin (Hb) of 8.2 gm/dL (normal range: 9.5–14.0 gm/dL) with high total leukocyte count (TLC) of 20, 790/μL with neutrophils of 54%. The platelets are normal. Her liver function tests showed high serum glutamic-oxaloacetic transaminase (SGOT) (589 IU/L, normal range: 10–40 IU/L), high serum glutamic-pyruvic transaminase (SGPT) (189 IU/L, normal range: 10–40 IU/L), and bilirubin (14.3 mg/dL, normal range: 0.3–1.0 mg/dL) was also significantly raised with conjugated fraction also high. The international normalized ratio (INR) was high at 1.9 (normal range: 0.9–1.2). The urine culture showed Escherichia coli (E. coli). The blood was sterile, and other serological workups for typhoid, dengue, and malaria were negative. There was the presence of pericardial effusion on echocardiography, after which she was referred to PGI and admitted to the pediatric emergency ward.

On examination, the hemodynamics were stable, and the blood sugar at admission was 151. She had significant pallor, icterus, edema, and palmar erythema. There was no cyanosis, clubbing, lymphadenopathy, or any skin bleed or bleeding from any other site. Her weight was 11.6 kg, which was appropriate for her age. On systemic examination, the abdomen was distended, liver was palpable 9 cm below the right costal margin. The liver was significantly firm to hard with a sharp leafy margin. The left lobe was also significantly enlarged, which was 8 cm below the xiphisternum. The liver had a smooth surface, nontender. The spleen was palpable 3 cm below the left costal margin. There was the presence of free fluid in the peritoneal cavity. The cardiovascular and respiratory systems were unremarkable at admission. At the time of admission at PGI on the 6th, the Hb was 7.7 gm/dL with leucokytosis and normal platelets. Gradually, on the 11th, she had a significant fall in the Hb of 3.3 gm/dL, which required blood transfusions and improved later. Her TLC was significantly higher (58,300/μL, normal range: 6,200–17,000/μL) with a polymorphonuclear response. Platelets gradually started falling down from the 8th onward, with a significant fall subsequently. Her C-reactive protein (CRP) was high (61 mg/L, normal: <0.6 mg/L), and the peripheral smear showed macrocytosis, ovalocytes, acanthocytes, fragmented cells, and a few stomatocytes (Table 1). The procalcitonin was high, that is, 4.4 ng/mL (≤0.1 ng/mL), serum ferritin was 3079 ng/mL (normal range: 7–140 ng/mL) which was high, lactate dehydrogenase (5538 units/L, normal range: 143–370 units/L) was high, uric acid was normal, and vitamin D (4.75 ng/mL, normal: 30–100 ng/mL) was low. The blood culture grew Acinetobacter at the time of admission, which was sensitive to imipenem and amikacin but resistant to ceftazidime and cefixime. The subsequent blood cultures on the 13th and 14th were sterile, including a urine culture done on the 9th. Ascitic fluid was tapped, which had a total count of 141 with 53% polymorphs, proteins: 88, sugar: 693, serum ascites albumin gradient: 1.8, and occasional pus cells on grams stain, but the culture was sterile. A galactomannan index was 0.55. An upper gastrointestinal (GI) endoscopy was done on the 8th, which showed increased vasculature in the lower end of the esophagus. The stomach had features of mild portal hypertensive gastropathy through fundal varices. The duodenum was normal with no varices and was visualized till D1. On suspicion of Indian childhood cirrhosis (ICC), 24-hour urine copper was done, which was very high: 4750 μg/day (normal <50 μg/day). Serum copper was in the normal range of 144 μg. On admission, bilirubin was 20 mg/dL, which gradually went up maximum up to 45 mg/dL, and conjugated up to 27 mg/dL. Similarly, SGOT increased significantly, along with alkaline phosphatase (ALP) (274 IU/L) on the higher side. Initial urea and creatinine were normal, which started increasing with a more than threefold increase at the time of demise. Then ammonia, at admission, was 139 µg/dL, which remained high preterminally as well. The lipid profile was normal (Table 2). The coagulogram revealed deranged INR both from outside to at admission. All the coagulograms showed deranged with all prothrombin time, prothrombin time index (PTI), and INR on the higher side (Table 3). The blood gas analysis at admission was on the normal side; the CO2 was low, but lactate was normal. On the 16th, the lactate suddenly increased, and then gradually, the child worsened because of her preterminal illness (Table 4).

Table 1: Shows complete hemogram
Lab investigations: hematology
03/09 (outside) 05/09 (outside) 06/09 08/09 10/09 11/09 12/09 14/09 16/09 17/09
Hb 8.6 8.2 7.7 6.7 6.4 3.3 9.0 6.4 9.0 12.4
TLC 15,680 20,790 17,800 27,660 19,600 58,300 59,000 41,990 47,400 59,400
DLC N54 L33 40/53 71/22 61/31 58/36 72/21 81/12 80/9 79/13
Platelet (103) 267 230 226 129 118 137 78 64 29 90
CRP 42 61 34 24
PBF Macrocytes+, ovalocytes, acanthocytes+, fragmented cells+, few stomatocytes+
Table 2: Shows biochemical parameters and Lipid profile
Lab investigations: biochemistry
03/09 05/9 06/9 07/09 08/09 09/09 10/09 11/09 13/09 14/09 15/09 16/09
Na 133 135 134 129 130 139 150 152 139
K 4.1 3.3 2.6 4.6 5.1 4.3 3.7 3.9 3.8
Cl 98 101 98 102 101 113 114 104
Urea 13 11 11 15 20 45 45 92 105 54
Creatinine 0.28 0.33 0.33 0.27 0.32 0.5 0.54 0.67 0.71 0.81
TSP 4.9 4.6 4.3 3.9 4.2 3.9 3.9 3.5 3.5
Albumin 2.5 2.5 2.5 2.8 2.8 2.9 2.7 2.7 2.5
TSB 14.3 24.4 20.2 17 17.6 22.6 45.4 29 40.4 38.1 27
Conjugated bilirubin 6.6 14.2 10.7 9.1 9.9 10 27 14.6 23.6 20.5 13
AST 589 355 370 713 556 452 1572 1708 1308 1041 1133
ALT 189 127 101 135 97 40 71 71 37 31 68
ALP 36 166 131 108 274 226 170 116
Ca2+ 8.1
PO4− 2.0
γ-glutamyl transferase 185
Ammonia 139.6 71.2 133
Triglyceride 230 179
Cholesterol 125 104
High-density lipoprotein 12.3 14.7
Low-density lipoprotein 107.3 98.3
Table 3: Highlights coagulation profile
Lab investigations: coagulogram
3/09 (outside) 05/09 (outside) 06/09 08/09 13/09 14/09 15/09 16/09
PT 27.3 49.9 86.9 34.9 62 112.5
PTI 42 23 13 33 19 10
Activated partial thromboplastin time 51.8 72.3 111.6 49.9 56 78
INR 2.55 1.9 2.3 4.3 7.49 3.0 5.3 9.7
Table 4: Shows venous blood gases
Lab investigations: venous blood gases
06/09; 03:46 PM 16/09; 09:56 AM 17/09; 11:42 AM 17/09; 2:34 PM 18/09; 04:00 AM
Ph 7.58 7.32 7.18 7.027 6.85
PO2 136 8.1 5.8 9.3 8
PCO2 21.9 40.9 51.2 53.5 81
HCO3 21 20.6 16.3 11 9.5
BE/BD −4.1 −9.7 −17 −18
Sat 70 70 85 72
Lactate 0.6 10.3 18 20 23

OTHER INVESTIGATIONS

α-fetoprotein: 18.44 μg/L (normal: <25 μg/L)

RADIOLOGY

Chest X-ray—three chest X-rays were done, first on 14th September, which appeared to be nearly normal with few small infiltrates in the left upper lobe of the lung. The subsequent chest X-ray on 15th September showed a mild increase in similar infiltrates. The third chest X-ray done on 17th September showed similar findings with few additional ill-defined infiltrates. A differential diagnosis of infection-related infiltrates was suggested.

Ultrasound for kidneys, ureters, and bladder done on 8thSeptember showed normal-sized kidneys with normally maintained echotexture, the liver was 10.4 cm (heterogeneous echotexture), spleen 7.6 cm, portal vein was 8.9 with normal flow, hepatic vein, and inferior vena cava was normal and had moderate ascites.

MANAGEMENT AND COURSE DURING HOSPITAL STAY

At admission, she was started on oral rifaximin, IV cefotaxime/amikacin, and IV furosemide. She also received IV vitamin K, multivitamins, medium-chain triglyceride oil, calcium, and zinc. In view of high urine copper and suspected ICC, she was started on D-penicillin on D9. Additionally, IV albumin and fluid restriction were initiated to manage increasing anasarca. On day 5, she developed oliguria, cola-colored urine, and a sudden fall in Hb (6.4–3.0). A possibility of hemolysis/ICC was kept, and she underwent plex (five cycles) and received a blood transfusion. On D8, she became anuric with acute kidney injury (AKI) and received hemodialysis (four cycles). For Acinetobacter baumannii sepsis, IV meropenem was started on day 6. She developed respiratory distress on D5 due to fluid overload and required continuous positive airway pressure support. On D5, she had methemoglobinemia (10.5%), was given vitamin C, and gradually improved. She also had hypoglycemia, requiring a 25% dextrose infusion. A day prior to her demise, she developed encephalopathy and refractory shock, requiring mechanical ventilation and inotrope infusion. Preterminally, she developed arrhythmia and refractory shock, which was managed as per protocol but could not be revived.

FINAL CLINICAL DIAGNOSIS

Cause of death: Multiorgan failure, refractory shock, and AKI.

CLINICAL DISCUSSION

Prof S Jain: Thank you, Arun. Please come and join me. Dr Arun has presented a case, and he believes that this is a case of ICC, a clear-cut case. But I believe there is something more than that. So, now we have first the comment from the treating unit if somebody wants to add it. Dr Sadhna, would you like to add? Any resident who has seen the patient during life?

Dr Keshav: Good morning, everyone. Actually, to clearly say it is an acute or chronic liver disease is quite difficult because the course of the ICC itself behaves like this. In the sense it has, as you mentioned, so there are four different stages. So course of the disease itself has different stages. Hence, it is more of a decomposition of the underlying disease itself rather than acute or chronic. The acute, the sepsis, and other things came up quite later. So, it’s more of a decomposition of underlying disease. That is one thing I want to say that a very high urine copper in our setting is usually nothing but ICC. In this particular patient, the history was very much clear. Though the existing epidemiological studies say that almost 46% of patients of so-called ICCs don’t have copper exposure, whatever cases we have seen, 100% have exposure to copper vessels, especially the milk-boiling copper vessels. So, the copper actually attaches to the milk protein, which is the mechanism. In this particular case, we didn’t actually have a second diagnosis other than ICC. Thank you.

Prof S Jain: Thank you. Yes, please.

Prof Verma: I think I have not seen enough cases of ICCs to comment on whether ICC is there or not. One thing is very striking in this patient, that is the serum bilirubin. Bilirubin to the tune of 25 and going up to 40. So, as a protocol, if bilirubin crosses 25 or near 25, it’s always hemolysis, which is very sure. But what is precipitating that is something we need to find out. In our setup, hepatitis A infection is known to cause this kind of presentation. Unfortunately, I could not see the immunoglobulin M hepatitis A levels in this case. So, hepatitis A infection causing severe hemolysis in glucose-6-phosphate dehydrogenase-prone patients is a very common scenario. So that’s why the hepatitis A vaccination in our setup is really very important.

Prof S Jain: Yes, Dr Sadhna.

Prof Sadhna Lal: I think valid comment by Dr Verma for a nonhepatologist. But you have to remember that hepatitis A almost never causes severe disease in infants unless there is an underlying problem. As rightly pointed out by Keshav, this acute-on-chronic liver failure (ACLF), though we ourselves have published a couple of papers, I think even in adult literature, you will see over time that it is going to become a matter of semantics. The term ACLF was introduced to identify a set of patients, whether adult or pediatric, who may deteriorate and would have a high mortality at the end of 4 weeks. So, going by the definition, only 1 month has seen this child; it would not fit into chronic liver disease, but that is the behavior of ICC. That is precisely what ICC does. And I think macrovesicular and microvesicular steatosis would not happen in an infant’s liver unless there is some underlying metabolic problem, which we are not really suspecting in this particular scenario.

Prof S Jain: Thank you. Yes.

Consultant 1: I think the margin and firm liver and all the things that are mentioned are a sitter, probably for all pediatricians. So we can’t get away from ICC. But I remember doing a similar case in clinicopathological conference (CPC) about 4–5 years back with all the copper indices that were markedly deranged in that particular patient. So, in that child, it turned out to be a veno-occlusive disease (VOD). That was a small child, again, a 1- or 2-year-old child. So, my point here in this particular case is not to get led by the copper indices as ICC or Wilson. It can be seen in other chronic liver diseases also. I’m sure my PG colleagues will correct me if I’m wrong. But here you’re having a disproportionately high bilirubin, not so much elevated enzymes. You have a marked coagulopathy of a liver that is large. Ascites in the absence of varices or portal hypertension, whatever you have looked at, and pericardial effusion, whether we should be thinking in terms of venal occlusive disease, which could be a cause for the chronic liver disease, and the copper indices, which are altered.

Prof S Jain: You’ll be surprised that when I was a resident, Dr Walia actually showed me on the third floor a number of cases that had sharp leafy margins. I used to say, you know, like I still remember, you know, visually I can, a young child with the protuberant abdomen, put your hand, sharp leafy margin with left lobe enlarged. He says, my dear boy, this is ICC. Take it from me. And, you know, majority of the times, liver biopsies were done maybe in 50%, not all the time, but, you know, that’s my, and in our times, it was a very, very common thing. Maybe the copper vessels were very common, and now the copper vessels have been taken off. So maybe that is the reason. Maybe you can correct me, or Sadhna can correct me. That is why suddenly, ICC has gone down, and now there are only case reports.

Prof Sadhna Lal: Yes, you are right that ICC has really diminished, but we are still seeing it. It still rears its head, and we see about two or three cases per year. Earlier, when I was a resident at almost the same time as you were, at that time, the ward always had two or three theses going on; there were always four or five ICC cases lying in the ward. So, the presentation here is typical. The question of VOD arises in the mind when you have a history of complementary and alternative medicine intake and the patient presents with ascites. So it is the reverse. It is the ascites which is the striking feature, and jaundice comes later. This child, with high bilirubin, came very, very prominently. And the enzymes were pretty high in the beginning. The SGOT, SGPT, aspartate aminotransferase (AST), and alanine transaminase (ALT) were pretty high in the beginning; then they crashed toward the end after the hemolysis had happened, again indicating that it is the rush of copper that is causing the necrosis. I don’t know whether Suvradeep is going to show us a surprise. But I would expect, I don’t know whether we have got the liver copper, so I would expect a very high liver copper, very high urine copper is already there with us, and the satellitosis, the chicken-wire fibrosis, and the Mallory hyaline, I don’t know. Let us see what he has to show us.

Prof S Jain: Yes. Any other comments about the infection? The liver always attracts fungus. Are we dealing with bacteria, fungi, or what? Just trying to ask people if somebody likes to comment. If not, I believe, Suvradeep, now you have to show us whether we are dealing with all the 90% chances, the pretest probability that this is ICC.

Autopsy Protocol

Thank you, sir. Good morning, everyone. So today, we are going to see the partial autopsy of a 12-month-old girl child. The prosectors noted that there were ascites but did not measure the quantity and did not mention the pericardial or pleural effusion.

Liver (gross examination): The liver weighed 450 gm, which was within the normal range, and grossly, the liver had a very sharp margin. The capsular surface appeared to be smooth with a certain degree of small nodularity or microgranularity, and the cut surface was little bile stained (Fig. 1). The extrahepatic biliary tree was patent all throughout, and the portal vein did not show any thrombus.

Figs 1A and B: (A) Gross photograph showing organ complex comprising of a slice of liver and gall bladder, C-loop of the duodenum, pancreas, and slice of the spleen; the cut surface of the liver shows microgranularity; spleen shows multiple large pale infarcts; (B) the capsular surface of liver also shows similar microgranularity

Liver (microscopic examination): The scanner view shows relatively darker pinkish hepatocellular islands, which are surrounded by a pale matrix material. The Masson’s Trichrome stain highlights this matrix material quite densely, which means that there is a good amount of fibrosis. The fibrous septae are seen connecting the major vascular structures, indicating porto-portal, portocentral, and, more importantly, centro-central kind of bridging fibrosis, causing distortion of lobular architecture. In the usual situation, distortion of lobular architecture is invariably accompanied by nodule formation, but if you look at these hepatocytes, you cannot really say that there is a good amount of nodule formation; rather, there are attempted nodules (Figs 2A and B). This kind of attempted nodule formation is typically micronodular cirrhosis. The reasons for this kind of attempted nodule formation rather than the formation of a true nodule are that there is dense fibrosis, which is creeping into the sinusoids, dense perisinusoidal fibrosis separating out the hepatocytes dominantly in the perivenular areas but essentially involves the whole of the acini (Figs 2C and D). The second reason for this relative lack of nodule formation is obviously the lack of regenerative activity by the hepatocytes. In fact, all the hepatocytes throughout the acini showed degenerative changes and an absence of regeneration. The reticulin stain highlights not only the perisinusoidal fibrosis but also this relative lack of regenerative changes. In addition, the hepatocytes show panacinar ballooning. Obviously, you can see this kind of intermediate filament clumping, which is very, very eosinophilic, which is Mallory hyaline, of course, and neutrophilic satellitosis causing the hepatocellular injury and death (Fig. 2E). Masson’s Trichrome stain highlights the Mallory hyaline in every possible hepatocyte as clumped slaty gray or deep fuschinophilic material (Fig. 2F). The other change that we saw here was the centrilobular changes in the central veins. The central veins show myxoid changes in the intima with inflammation. In some places, the inflammation is not there, although there is near occlusion of the central veins, and this kind of change is also known in ICC (Fig.2G). Now, what is absent? Number one is the inflammation. There are only occasional patches of the portal and lobular inflammation. Number two, steatosis was not present, and in contrast, you can see there are some ductular reactions and ductular cholestasis, which is possibly related to septicemia. And this ductular reaction is well brought out by the cytokeratin 7 immunostain. So, just summarizing the hepatic histomorphology in this particular case, we saw micro micronodular cirrhosis, possibly which are related to perisinusoidal fibrosis and the absence of regeneration of the hepatocytes. A lot of degenerative changes in the hepatocytes in the form of ballooning, Mallory hyaline, and neutrophilic satellitosis. There is an absence of steatosis, and there is absence of or minimal degree of inflammation. So obviously, the next question is, what is the copper? So when we performed rhodanine stain, almost all the hepatocytes and not the other structures showed a lot of copper positivity as the reddish blush in the low magnification, and of course, in higher magnification, almost all the hepatocytes showed very coarse granular rhodanine positivity related to copper (Fig. 2H). The tissue copper level performed was 1998 μg/gm of dry weight (reference range: 10–40 μg/gm, courtesy: Professor Savita Verma Attri, Department to Biochemistry, PGIMER, Chandigarh). So, there is a little bit about ICC, which has, of course, a reducing trend. It has a characteristic histopathology. This patient has given a history of brass utensil use although that is doubtful according to some papers. So now let us look into the complications that this particular disease has caused.

Figs 2A to H: Microphotographs from the liver (A) Showing low power view with the presence of tiny hepatic islands surrounded by pale matrix material [hematoxylin and eosin (H&E) stain at 4× magnification]; (B) Pale matrix is highlighted on Masson’s trichome stain as dense fibrosis (Masson’s trichome stain at 4× magnification); the fibrosis is pericellular, involving complete acini, predominantly in the perivenular areas as shown in (C) H&E stain at 10× magnification; (D) (Massons trichrome stain at 10× magnification), the hepatocytes showing Mallory hyaline as deep eosinophilic intracellular material and neutrophilic satellitosis; (E) (H&E stain at 40× magnification), Mallory hyaline is highlighted as slate gray fuschinophilic material in Masson’s trichrome stain; (F) 40× magnification; (G) Masson’s trichrome stain showing vascular changes in the form of intimal proliferation leading to near obstruction of the centrilobular vein (20× magnification); (H) Rhodanine stain highlights dense positivity in the hepatocytes (40× magnification)

Spleen (gross examination): Spleen weighed 175 gm, three times the upper limit of normal, and grossly, you can see that there are splenic infarcts (Fig. 1A).

Spleen (microscopic examination): In the microscopy, you can see relative white pulp depletion and a relative preponderance of the red pulp. And you can see this well-demarcated area of infarct. And when we looked closely at the infarct, we could see these recanalizing thrombi.

Gastrointestinal (GI) tract (gross and microscopic examination): Although endoscopy-wise there were no varices, we looked into the esophagus, the stomach, and small and large intestine, and in all these areas, in the submucosa, we could document histologically this kind of thick-walled arterialized veins, which were at places dilated and congested, conforming to the portal hypertensive changes in the submucosal vessels (Figs 3A and B).

Figs 3A to D: Microphotographs from the stomach (A) Showing arterialization of veins in the submucosa (H&E stain at 10× magnification); (B) Masson’s trichome stain at 10× magnification; (C) Epithelial ulceration with hemorrhage in the submucosa (H&E stain at 4× magnification); (D) Higher power picture highlighting angio-invasive fungal profiles (periodic acid–Schiff stain at 20× magnification)

Kidneys (gross examination): The kidneys were swollen (weight: 200 gm, reference range: 37–93 gm), definitely overweight, and a little bile stained. The cut surface did not show any focal lesion, but there was a distinct corticomedullary junction (Fig. 4A).

Figs 4A to D: Gross photograph showing swollen kidney, which is bile stained; (A) The corticomedullary junction is maintained; microphotographs from kidney showing bile pigment casts (star mark) predominantly in the renal tubules; (B) (H&E stain at 10× magnification), acute tubular injury in the form of loss of brush border; (C) Simplification of epithelium and loss of nuclei (H&E stain at 20× magnification); (D) Presence of copper deposits as Rhodanine positivity (Rhodanine stain at 40× magnification)

Kidneys (microscopic examination): In the low magnification, although the glomerular and vascular compartments were normal, you can see that numerous tubules, especially the proximal tubules, were full of pigment casts (Fig. 4B). In addition, of course, there is at least moderate to severe degree of acute tubular injury, as is highlighted by the dilatation of the tubular epithelium, simplification of the epithelia and loss of brush border (Fig. 4C). So obviously this paper has been quoted by Arun sir also and we don’t know whether this is immune complex-mediated or not, but there was definite evidence of hemolysis.1 The other change that was very important was the abundant deposition of copper inside the proximal tubular epithelial cells. In fact, I performed rhodanine in two or three sections; in all those sections, it was loaded with copper (Fig. 4D), and when we looked into the literature, an elite group from King’s College Hospital had documented the orcein-positive copper metal deposition in the kidney as well, which also give rise to renal dysfunction in the patients of ICC.2

Terminal Illness

We have already seen certain evidence of septicemia in the liver in the form of ductular reaction and ductular cholestasis.

Lungs (gross and microscopic examination): The lungs’ weight was a little heavier (305 gm, reference range: 88–292 gm), a little bit of dullness, especially of the pleura, especially over the lower lobes, and you can see that there are multiple hemorrhagic nodules, especially which are very much solid especially in the lower lobe as well as in the upper lobe and you can see that these hemorrhagic nodules involve both the lobes (Figs 5A and C). Whenever we see such hemorrhagic nodules in gross, we obviously look into the bronchus, and you can see that this is a bronchus and can you see that there are certain hyphae which are there infiltrating through the bronchial tissue into the underlying capillaries (Figs 5D and E). These fungal hyphae are very much septate and show acute angle branching. In places, these fungal hyphae were clogging the pulmonary arteries, and obviously, there is angioinvasion. Periodic acid–Schiff (PAS) stain brings out these fungal hyphae with acute angle branching conforming to the morphology of Aspergillus. We submitted the block for typing of the fungus. However, there was no amplification by polymerase chain reaction, possibly because this is an autopsy tissue. In addition, the rest of the areas of the lung showed hyaline membrane formation, which is the eosinophilic material around the alveolar ducts, which were also PAS-positive.

Figs 5A to E: Gross photographs of lungs (A) Showing lusterless pleura on the outer surface), areas of hemorrhage in bilateral lungs; (B) Left lung; (C) Right lung; (D) Microphotographs showing invasion of bronchi by fungal profiles (H&E stain at 10× magnification); (E) Higher power showing fungal profiles as septate hyphae with acute angle branching confirming to Aspergillus (H&E stain at 40× magnification), which also showed angioinvasion

Stomach (microscopic examination): This fungus was not contained only in the lung but had also spread to the stomach. There was a small hemorrhagic ulcer in the stomach, and you can see that this is the ulcerated lining epithelium. This is the hemorrhagic base within which there are vessels that are clogged by the fungus, similar morphology, which is invading the tissue (Figs 3C and D). And these are the fungi that are causing angioinvasion and spreading into the rest of the stomach.

Heart (gross and microscopic examination): The heart weighed 50 gm, which was normal (reference range: 32–64 gm), and all the chambers and valves were within normal limits. Microscopy of the heart was also normal, and the valves were within normal limits.

Pancreas, ovaries, thyroid, and adrenal: Gross and microscopic examination did not show any pathologic findings.

Bone Marrow: A little bit of bone marrow material was present for evaluation; it showed some degree of erythroid hyperplasia, and other hematopoietic lineage elements were adequately represented.

Final Autopsy Diagnosis

This 12-month-old girl child is:

  • Indian childhood cirrhosis (ICC) with portal hypertension (varices, portal hypertensive gastroenterocolopathy, and splenomegaly with splenic infarct and ascites).

  • Pigment cast nephropathy with acute tubular injury.

  • Excess copper deposition in tubular epithelial cells.

  • Angioinvasive aspergillosis (lung and stomach).

  • Diffuse alveolar damage (exudative phase).

(Flowchart 1 depicts the timeline of the disease and its complications).

Flowchart 1: Flowchart depicting the timeline of disease and its complications

Prof S Jain: Thank you, Suvradeep. Please come and join me. Can we have one more chair, please? Now, Suvradeep, before we start, can you tell us how to differentiate Wilsons from ICC or what you know whenever there is a copper deposit for us? The standard thing is Wilson’s, but yes, we know that in ICC also. Is the pathology different, or could there sometimes be confusion?

Dr Suvradeep Mitra: So obviously, the clinical profile is different histopathologically. In Wilson’s disease, at this point in time, we can see macronodular cirrhosis. You can see steatosis in Wilsons, which is usually absent in ICC. Then the Mallory hyaline, the neutrophilic satellitosis, and the features of copper deposition are usually seen in the periportal or periseptal region in Wilsons, unlike ICC, which is much more diffuse and usually has a centrilobular preponderance. The pericellular fibrosis in Wilson is extremely unusual. So, there is an absolute histological difference between Wilson’s disease and ICC.

Prof S Jain: Thank you, just giving time for people to think. Madhumita, would you like to comment? You have worked in Delhi, so what is the situation there?

Dr Madhumita: So we hardly see any patients of ICC. I mean, my generation has not really seen it, which is why I actually came here to learn today, and I was sitting quietly. Just one point is that this patient certainly had massive hemolysis because there’s a dissociation between the AST and the ALT, so probably that, you know, massive rise in bilirubin as well. Although one can say it is ACLF, it could also have been a hemolytic crisis, and that could have caused the tubular tubules to get blocked by acute tubular necrosis and the patient to have secondary organ failures. Naturally, this kind of immune dysfunction comes in; when there is so much hemolysis and so many cytokines, then this fungus must have come in. I am not sure whether iron, like copper itself, has some association with fostering bacterial growth, but yes, the fungus coming here is classical with ACLF. So yeah, have a little borderline about whether one could cause it, say it is ACLF, or whether the hemolysis and that kind of event only cause the terminal event finally or the secondary organ failures.

Prof S Jain: I believe you know functional things are very difficult to diagnose pathologically. So yes, please.

Consultant 2: Environmental toxins and genetic conditions mimic closely. So is there any way Dr Suvradeep that histopathologically, we can say this is because of environmental copper or genetically mediated condition because the ICC diagnosis was in the pregenetic era, and most of the conditions now we are wiser than we had assumed because of environmental toxins are now because of genetics and it is also a good idea to do genetics in such cases.

Prof S Jain: I believe you know it is unlikely to be genetic because if it was there, then ICC would not have come down. You know, the epidemiologically straight, you know, with the use of brass vessels going out of fashion. Yes, I am just trying to buy time, Dr Saab. I am just trying to say that, you know, those people who are having dal makhani at heavy restaurants because brass things are the usual, you know.

Prof Sadhna Lal: So, ICC genetic ideology, I mean there was this couple of papers which I have thrown this, and there is a phenotype which is seen in North America where there is no copper excess. But what is believed best is because we have seen a crash of the incident. Now, there are only small pockets from where these patients will come. From Rajasthan, a couple of areas in Himachal, and one or two areas in Punjab, almost all our patients are coming; I mean, we do not have so many cases at all actually these days. So, it is thought to be because of the immature copper metabolism, which we all study in biochemistry. So, the infant has an immature copper metabolism, and the capacity to incorporate it into the apoceruloplasmin is low. So, that is why, in the face of a huge insult in the form of a huge intake of copper, as happened in this child. Actually, this child is very, you know, it is very sad. She was in in vitro fertilization, and the parents had not had a baby for 12 years; they went in for in vitro fertilization, and then somebody told them copper is a very good thing; it is healthy. They started consciously using copper vessels so that their baby would do well. So it’s really sad. But it is mostly to do with the immature. I am not saying we can exclude genetic etiology; maybe we would have to have a number of cases to be able to look at that. It would be basically because of the immature copper metabolism in the infant, which is exposed to a huge load of copper. I think the residents sitting here are very lucky they have seen a classical textbook picture of ICC, micronodular cirrhosis, lack of regeneration, chicken wire fibrosis, satellitosis, Mallory hyaline; you name it. So this is something that should stay in your minds, and I think because we don’t see these patients very often. Another thing that is very interesting in this child is the evidence of portal hypertension. Classically, what we are taught that ICC evolves so very rapidly, so rapidly, just gives you a few weeks that portal hypertension splenomegaly does not get time to happen, but I think this is all old literature, and one doesn’t know how meticulously portal hypertension has been explored in the previous cases so this is really very, very very interesting. ACLF, again, you know, as I said earlier, it’s a matter of semantics for me. I mean, if I am a pediatrician, now, if you want to have a category of ACLF, I would say, ok, hemolysis is one of the precipitants. So, you have an acute insult, and you have a chronic is difficult to call in this patient because the history of the illness is the exposure to copper there for 6 months, but the history of the illness in this patient is very low. So, I mean, it is a matter of semantics. What I think you basically have to do is understand the pathophysiology of the disease.

Prof S Jain: Yes, please.

Consultant 1: Good morning. Around 7–10 years back, when we were doing a residency, we saw a lot of ICC patients in an emergency, inward, and in pediatric gastroenterology. We were like in last few years the number has significantly decreased. So, I thought it might be patients not coming to an emergency, or they are going directly to gastroenterology, or we have stopped going to gastroenterology, but the conclusion is that over time, the incidence has decreased significantly. My question is, what is the reason for this child having normal serum copper? Is it known in ICC that the liver is accumulating copper, or is it due to chelation or plasmapheresis cycles?

Prof S Jain: I think it is a very valid question that when hemolysis occurs, it is possible because of free copper, as you can understand.

Prof Sadhna Lal: Yeah, this was obviously initially enzymes are high, crashing because you can see hardly any hepatocytes. There has been a massive release of copper, so very difficult to explain. We tried a very nonconventional therapy in this. Nobody ever in the world has tried, I mean, in India has tried plasmapheresis for this. But we thought the same analogy, that the thing is because of copper, so let us try plasmapheresis because these parents are desperate and cannot afford a transplant. We told them this child could be saved only if they gave her a transplant. So this is very strange why this copper was low. The residents told me that it was sent before the plasmapheresis. So it’s very difficult for me to explain this. One would have expected a high copper.

Prof S Jain: Yes. So last time, we saw an exogenous toxin, which was in the form of pyrazolidine, which was possibly related to green tea. Today, we have seen copper. So please be careful about what you eat, drink, and breathe. Yes, you have to stay alive, and let me scare you by telling you the real story of banana ripening. So you can look, and I have seen it. So I think we should be very careful and at least wash your fruits, see in what type of environment you are eating and what you are eating and drinking. It’s extremely important, but we forget. Please remember the arsenic story. I am not trying to say because one case is only the tip of the iceberg. It tells you that if one case is, there may be 10. But I believe that all ICCs would come to light. Is that right? Or there will not be any subclinical cases. Or can it reverse back if the person stops taking it? Yes, please.

Prof Sadhna Lal: Very interesting point you made. Actually, it is all to do with the age at exposure. A few years ago, we discussed a case in this hall. Arushi was there as the clinician who presented the case, in which there was no obvious copper exposure. There were two siblings; we thought it was genetics, but it became very high. Now then, there was a difference; there was the sibling who escaped, and children presented to us at around 1 year and 6 months of age. So one child died, and the second child, who had a similarly high copper but had a little lesser, I mean, was predominantly breastfed, was not having top feeds. So, we presumed at that time that this was possible because of the fact that exposure in the second sibling started late. The other sibling was totally top-fed, which is why he presented that though we could not prove it, we could not get hold of the samples of the water or the area to show whether there was excess copper in the water supply itself. That is one of the theories. That there may be excess copper, I mean you may be having a bedrock which is rich in copper and you are having the wells going there and those, that water is being consumed, then that water is intrinsically high in copper.

Prof S Jain: Yes, please. Please identify yourself.

Dr Sunil: Good morning, all; I am Dr Sunil, SR, Pediatric Nephrology. So, my question is, for this child, the serum copper was normal, and the copper levels in the tissue were also very high. So, is there any role of MARS, which is a molecular adsorption recycling system, over normal plasmapheresis in removing the copper load in this child?

Prof Sadhna Lal: Yes, you can see the serial values.

Dr Sunil: Yeah, most likely. Because there was bile cast nephropathy, the other tissues were very high in copper. So, most likely, the serum values were.

Dr Arun Bansal: So the right thing is you made a very valid point, and it was asked also. Whether it was copper usage or genetics? There are also studies Madam highlighted; Arushi and Kirti published a case in which there was no exposure to copper, but it still had ICC. So, there are reports showing that up to 40–45% of cases do not have exposure to copper but still have ICC. But they also could not find with the limited resources that genetic causes are there or not. So, we do not know. They have also looked at the exposure to the food and water copper levels, and they could not correlate it with the development of ICC. So there is something more maybe going on.

Prof S Jain: So Kirti wants to add something. Do you want to talk about the copper in the brain or something? A hepatolenticular degeneration or something.

Prof Kirti Gupta: So, not about the copper in the brain, but definitely, this case was discussed then, and there were two siblings. The child who died obviously came for the autopsy, and then the cause, as genetics being the etiological factor, was strongly suspected, but we could not prove it, and it was this that also showed all the features of ICC. So, I would say genetics was very strongly suspected at one time when this ICC diagnosis was evolving, and then the thing about the North Indian, what they call increased copper, was strongly gaining a foothold. But then genetics was never proved in that also.

Prof S Jain: Thank you. So, any other comments? If not, if there are no other comments, then I thank both the presenters for the wonderful presentations. I am bringing to a notice that things which you believe have become extinct. Actually are not extinct, and we have to keep our eyes and ears open.

SUMMARY AND COMMENTS

Indian childhood cirrhosis (ICC) was first described in 1887 by Dr Sen in Calcutta (now Kolkata) as ”infantile cirrhosis,” though it is believed that the disease was known to Sushruta in 1000 BC.3 It is associated with massive copper/copper-binding protein retention/deposition in the liver during childhood, usually in <3 years of age with mild male preponderance. Initially, the association between copper/ brass-utensil use and disease occurrence was considered to be cause effect relationship. However, in a large study by the Indian Council of Medical Research, the presence of copper/brass vessel use was found to be incidental.4 The jar of genetics still remains unopened as cases with family history have been documented. Our case, on the other hand, had a classical history of brass vessel use. The disease is nearly fatal, as in the present case, with reversal after D-penicillamine therapy only if detected early.5 Two-thirds of ICC cases present with hemolysis and its complications, and the same was seen in our case.1 Histopathologically, characteristic morphology with micronodular cirrhosis, typical pericellular perisinusoidal fibrosis, toxic injury of hepatocytes in the form of Mallory hyaline, neutrophilic satellitosis, and excessive copper deposition were present. Additionally, there was copper deposition in the renal tubular epithelial cells as well, documented in 1978 by Tanner et al.2 Though the causal relationship of brass/copper vessel is now considered to be questionable, the incidence of the disease has significantly reduced, partly because of lesser use of brass utensils and rest is still to be discovered.

REFERENCES

1. Perkash A, Nair A, Bhorchi R, et al. Haemolytic anaemia in Indian childhood cirrhosis. Arch Dis Child 1971;46(245):46–50. DOI: 10.1136/adc.46.245.46

2. Tanner MS, Portmann B, Mowat AP, et al. Indian childhood cirrhosis presenting in Britain with orcein-positive deposits in liver and kidney. Br Med J 1978;2(6142):928–929. DOI: 10.1136/bmj.2.6142.928-a

3. Sen BC. Infantile cirrhosis of the liver. Indian Med Gazette 1887;22:338–340.

4. Nayak NC, Chitale AR. Indian childhood cirrhosis (ICC) & ICC-like diseases: the changing scenario of facts versus notions. Indian J Med Res 2013;137(06):1029–1042.

5. Bhagwat AG, Walia BN, Koshy A, et al. Will the real Indian childhood cirrhosis please stand up? Cleve Clin Q 1983;50(03):323–337. DOI: 10.3949/ccjm.50.3.323

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