DIAGNOSIS
The liver biopsy revealed neutrophilic infiltration of the portal tract and of the epithelium of the bile ducts (figures 1 and 2). The findings on liver biopsy were compatible with neutrophilic cholangitis. Antibiotics were discontinued. He was given pulsed steroids (1 g/day intravenous methylprednisolone for three days), then oral methylprednisolone 20 mg/day. His body temperature returned to normal after the first dose of steroids and the rash evanesced. The pain in his right upper abdomen improved. Methotrexate was added to the therapy and the steroid was tapered. ALAT, ASAT, bilirubin, and alkaline phosphatase returned to normal.
Psoriasis is a common chronic inflammatory disease, affecting approximately 2% of the world’s population.1 Although it primarily involves the skin, systemic involvement including the liver is common. Cholangitis in a psoriatic patient is a diagnostic challenge since these patients are frequently given immunosuppressive or immunomodulatory drugs. Neutrophilic cholangitis is a recently described entity characterised by neutrophilic infiltration of the biliary tree causing cholestasis.2 It has been described in patients with neutrophilic dermatological infiltrations such as Sweet syndrome, generalised pustular psoriasis and/or psoriatic arthritis.3 Increasing evidence shows that neutrophilic cholangitis is an extracutaneous manifestation of psoriasis and the frequency of liver involvement in psoriasis is high.3
Neutrophilic infiltration, in addition to involvement of the portal tract, is a predominant feature of cutaneous and extracutaneous lesions of pustular psoriasis, especially when the mucous membranes 4 and synovial membranes in patients with polyarthritis are involved.5
Recent data suggest that neutrophilic cholangitis has been underestimated and physicians should be aware of this involvement in psoriasis patients.3 Psoriatic skin lesions and neutrophilic leucocytosis supports a specific involvement of the biliary tract. Neutrophilic cholangitis should be considered in the differential diagnosis in a psoriatic patient with cholangitis.
REFERENCES