Acute Liver Injury of Unclear Etiology: A Case of Alcohol-Associated Steatohepatitis

A 37-year-old female was hospitalized for acute liver injury, presenting a diagnostic challenge that ultimately led to a diagnosis of alcohol-associated steatohepatitis (ASH). Steatohepatitis is a state of liver inflammation with fat accumulation and has several potential etiologies, including metabolic dysfunction-associated, alcohol-associated, drug-induced, autoimmune, and viral causes. A definitive diagnosis often requires a thorough clinical history, laboratory and imaging studies, and, in some cases, a liver biopsy. Our patient, with a history of gastroesophageal reflux disease, alcohol-use disorder, obesity, and systemic lupus erythematosus, presented with a one-week history of abdominal pain, jaundice, conjunctival icterus, and hepatomegaly without altered mental status. Laboratory results showed a total bilirubin of 12.5 mg/dL, aspartate aminotransferase of 237 U/L, alanine aminotransferase of 129 U/L, alkaline phosphatase of 424 U/L, and an international normalized ratio of 1.2. Right upper quadrant ultrasound revealed no biliary obstruction. Viral and autoimmune panels, as well as immunoglobulins, were unremarkable. Ceruloplasmin was low (0.09 g/L), 24-hour urinary copper was elevated (40 µg/24 hour), and slit-lamp examination was negative for Kayser-Fleischer rings. Liver biopsy revealed severe steatosis with prominent Mallory-Denk bodies, bridging fibrosis, and portal tract inflammatory infiltrates. These histologic features, together with a positive phosphatidylethanol test, led to the diagnosis of ASH. This case highlights an interesting diagnostic challenge of acute liver injury. Although ceruloplasmin was low and 24-hour urinary copper was elevated, these levels did not meet the diagnostic criteria for Wilson's disease. Liver biopsy suggested ASH, despite the patient reporting cessation of alcohol use. In cases of acute liver injury where history, labs, and imaging studies are inconclusive, liver biopsy is crucial for diagnosis. Treatment for ASH includes abstinence from alcohol and corticosteroids.