Granulomatous Hepatitis with FNH - Hepatitis Message Board

jackie1962 · 09-14-2008, 09:12 AM

I have seen nothing here about granulomatous hepatitis and FNH. I was diagnosed w/ both last year after 2 liver biopsies. The only slight elevation on my liver enzymes is the Alk Phos, which is around 145. Does anyone have any info about these, especially granulomatous hepatitis?? Thanks.

harka · 09-14-2008, 01:49 PM

Hi Jackie,

What are you referring to with FNH? Granulomatous hepatitis is generally found to be secondary to something else....for example, certain chronic infections such as brucellosis, Q-fever, tularemia, syphilis (just to name a few) can cause this entity. In your case, I see your liver enzymes were up--were you also having other symptoms?

You did also mention FNH...sorry, but I'm not familiar with that abbreviation.

harka · 09-14-2008, 02:06 PM

Hi Jackie,

I looked it up and realized I am familiar with FNH, though I know it as focal nodular hyperplasia. Is that what you're talking about? FNH is tehcnically nodules in the liver that, when you biopsy them, just contain normal liver tissue. I can't think of an association between FNH and granulomatous hepatitis, but there may be rare case reports I'm not aware of.

As I mentioned before, when someone has granulomatous hepatitis, usually the person is ill, has a fever, perhaps jaundice, and has evidence of hepatic dysfunction on blood testing and hepatic and splenic enlargement on imaging. Technically to make the diagnosis, you need a liver biopsy--I take it you've had one?

The issue with granulomatous hepatitis (GH) is that you have to search for an underlying cause. Many different things can cause it, as I mentioned, they can be chronic infections (bacterial, viral and parasitic), certain medications (like allopurinol or ingested mineral oil), lymphoma, and certain autoimmune diseases like primary biliary cirrhosis.

The most common causes for GH in N. America are extrapulmonary tuberculosis, mycobacterium avium complex infection, sarcoidosis, primary biliary cirrhosis and drug reactions. In about 20-30% of people, a cause for the GH will never be found, and they are often treated with immunosuppressants to slow down the inflammation.

jackie1962 · 09-14-2008, 05:11 PM

Thank you for your reply. FNH is focal nodular hyperplasia. As I understand it, FNH is a benign mass on the liver (I have 3 FNH masses on the left lobe). Initially, the doctors thought cancer, then cirhosis, and finally after months of tests, settled on focal nodular hyperplasia as my 1st diagnosis. No treatment for this, but he said if I would require surgery for some reason, it would be easy because of the location of the masses on the left lobe. No plans for a resection are deemed necessary at this time, thank God!

It is suspected that the granulomatous hepatitis in my liver is a result of histoplasmosis. I never tested positive for histo, but I was producing the histo antibody so it is assumed I had an infection. I had been sick 6 months previous and I do believe that is when I had the histoplasmosis infection going. Dr's also suspected sarcoidosis. I was told that the granulomas in my right lobe are focal non caseating portal granuloma.

All of this was found coincidentally when having a chest xray. I had no symptoms and currently have no symptoms. Because there was a small area in the lung affected by the histoplasmosis, and the liver involvement, I was given a diagsosis of disseminated histoplasmosis and had a year long course of sporanox. Dr. says it's possible that some liver damage could also be a result of the medication, methotrexate, that I took for several years for rheumatoid arthritis.

I take no meds currently, only a prn for arthritis when I really need it. While on the sporanox, I had monthly liver function tests that always came back normal with the exception of the slightly elevated Alk Phos. I just finished the sporanox and the infectious disease doctor says that I need no follow up. I guess after 2 liver biopsies, lung surgery, and a year of medication and liver enzyme tests, it's hard to think of it being over. I know that I have liver damage and want to do everything I can to help it heal if that's possible.

Hope this makes sense. Thank you for your thoughts.

harka · 09-15-2008, 08:48 AM

Ahhh, you left a HUGE part out of the story didn't you!

Yes, one of the more "common" causes of hepatits granulomatosis is an endemic mycosis such as histoplasmosis. I see you're from Nebraska, and I guess it makes sense that Histo is the dominant dimorph as opposed to Blastomyces, the dominant dimorph where I am from (SW Ontario, CANADA).

So you were treated with itraconazole for a year or so eh? It's kinda confusing reading what you wrote, because you said you were sick at one point and now have no symptoms. Were you having symptoms once you started on the intraconazole, and then they went away? Were you having fevers/chills/sweats?

You said you were producing the Histoplasma antigen--where did they find that? In your urine or blood?

Finally, whenever you find granulomatous inflammation, the diagnostic approach usually includes TB/fungus/sarcoidosis/lymphoma, and depending on which part of the body it is (like the liver) certain other conditions are added. They mentioned that methotrexate may have played a role. Possible--MTX is known to cause hepatitis, but interestingly, some cases of idiopathic granulomatous hepatitis are in fact TREATED with MTX! So, hard to know.

Another question: were you ever on any TNF-alpha inhibitors for your RA?