Rather, they are valued for their proven relation to important patient outcomes. The important step for a new method is the same: not “does it predict the biopsy

result,” but “does it predict the patient result.” Long-term follow-up of patients after extracting the new measure should be our target, along with serious thought about what that measure or measures should be. That is the gold standard for whether a new method is an important addition to the practice. “
“A 25-year-old woman from Vietnam presented with 3 weeks of yellowing of the skin. On admission, her alanine aminotransferase (ALT) level was 329 IU/L and her total bilirubin (TBI) level was 5.7 mg/dL. Serological markers for hepatitis A, B, C, and antinuclear and antimitochondrial antibodies were negative, www.selleckchem.com/products/cb-839.html but her anti–smooth muscle antibody (1:20) was weakly positive. Her serum ceruloplasmin level was normal. Corneal Kayser-Fleischer rings were not found. We initiated prednisolone 75

mg/day and made a tentative diagnosis of autoimmune hepatitis. ALT, alanine aminotransferase; ICAH, improved cholestasis but aggravated hepatitis; Ig, immunoglobulin; IHC, immunohistochemistry; PCR, polymerase chain reaction; TBI, total bilirubin. Two weeks later, the patient’s ALT level was 91 IU/L, and her TBI level was 1.6 mg/dL. After 3 weeks, her TBI level decreased to 1.0 mg/dL, but her ALT level increased to 360 IU/L. Orientia tsutsugamushi AZD6244 supplier immunoglobulin (Ig) M and polymerase chain reaction (PCR) analyses

were negative. A rapid plasma regain test (1:8) and Treponema pallidum hemagglutination assay (1:80) for syphilis were both inconclusive. Leptospira-specific IgG/IgM analysis was positive, but nested Protein Tyrosine Kinase inhibitor Leptospira PCR analysis was negative. A liver biopsy specimen revealed portal lymphocytic infiltration with blurred interface, bilirubinostasis with bile pigment within hepatocytes and Kupffer cells, and canalicular bile plugs (Fig. 1A, hematoxylin and eosin [magnification ×100]). Silver staining demonstrated a one-end hooked wavy spirochete (Fig. 1B, arrowhead [magnification ×400]). A long wavy Leptospira (arrowhead) and other leptospiral forms, including short rods (R), aggregates (Ar), and cocci (arrows), were revealed by way of leptospiral immunohistochemistry (IHC) staining using polyclonal rabbit anti–Leptospira interrogans antiserum (Fig. 1C [magnification ×400]). Initially, improved cholestasis but aggravated hepatitis (ICAH) occurred, during which the patient’s TBI level decreased while her ALT level increased (Fig. 1D, dotted circle). Finally, her aspartate aminotransferase and ALT levels decreased gradually to normal within 3 weeks after tapering prednisolone and using doxycycline followed by penicillin G. Leptospirosis is caused by Leptospira species endemic in nonurban areas. The clinical manifestations range from subclinical infection to febrile illness, jaundice, renal failure, and pulmonary hemorrhage.