Ground Glass-Like Inclusions: Associated with Liver Toxicity
Department of Pathology, Erciyes University, Faculty of Medicine, KAYSERI, TURKEY
Keywords: Pseudoground glass, Ground glass, Toxicity, Herbal, Mushroom, Liver
The etiology of ground glass-like inclusions is heterogenous and the pathology has been described in various conditions including
HBV infection, Lafora’s disease, fibrinogen storage disease, type IV glycogenosis, and alcohol reversion therapy. Similar ground glass-like
inclusions are also associated with immunosuppressed conditions and multiple medications, for which the clinical significance is still unclear.
Additional cases, some with previously unreported unique etiologies, and their follow-up were described in this study.
Materials and Methods: Eleven cases were examined between 2008 and 2019 for this study. The clinical data and histologic slides were reviewed.
All of the cases were negative for Hepatitis B virus. None of the patients declared alcohol intake or a history of epilepsy.
Results: Liver histology showed mild lobular inflammation in most of the cases (72%). Ground glass-like hepatocytes were distributed in the
patchy-panlobular, periportal, and centrizonal pattern at 55%, 27%, and 18%, respectively. Clinical history revealed medication use in nine (82%)
patients including NSAIDs, steroids, and chemotherapy. Ground glass-like inclusions were related to herbal toxicity in two of the patients. Liver
function tests were elevated in all of the cases. Follow-up data revealed four patients with malignancy who died of their cancer. Seven patients
showed resolution of elevated liver enzymes with a median follow-up period of 37 months (range 7-132 months).
Conclusions: Medication is the most relevant etiology for the development of these inclusions. Ground glass-like inclusions may also seen in
herbal toxicity. Transplantation was not an etiologic factor in our patients. Most of the patients displayed an indolent course with resolution of
the elevated transaminases.
Cytoplasmic ground glass appearance of the liver cells
was described in patients with Hepatitis B infection by
Hadziyannis et al. in 1973 (1). Similar-appearing inclusions
were then later described in a variety of etiologies including
myoclonic epilepsy, Type IV glycogenosis, alcohol reversion
therapy, and fibrinogen storage disease (2). In 1985, three
bone marrow transplant patients with bone marrow who
had eosinophilic inclusions in hepatocytes were reported
(3). These inclusions were named as pseudoground glass
change by Wisell et al. in 2006. In the current paper, 11 new
cases, some with new apparent etiologies, were described
together with the natural history, and a review of the
previously reported cases was additionally provided (4).
The files of the Pathology Department between 2008 and
2019 were searched for “pseudoground glass hepatocytes”
and “ground glass-like hepatocytes”. Eleven cases were
included in this study. Ethical approval was obtained from the Institutional Clinical Research Ethics Committee
(approval number 2020/241). The clinical data and medical
history of the patients were reviewed. None of the patients
declared alcohol intake or a history of epilepsy.
The slides of the liver needle biopsies were evaluated for the
degree and distribution of ground glass-like hepatocytes,
steatosis, inflammation, and fibrosis. Immunohistochemical
staining for HBSAg (1:50 dilution; Thermo Fisher Scientific,
Fremont, CA) was performed by using the Ventana Bench
Mark autostainer. Masson’s trichrome and PAS stains were
performed on the Ventana Bench Mark special stains
system. The phosphotungstic acid-hematoxylin stain was
Seven of the 11 patients were male and
4 were female (M:F=1.75). Their ages ranged between 17
and 75 years with a median of 37 years. Four patients had
an underlying malignancy including lymphoma, acute
myeloblastic leukemia, and gastric or lung cancer. One patient had chronic obstructive lung disease and one had
hyperthyroidism. An underlying disease was not found in 4
of the 11 patients. The clinical history revealed medication
use in nine (82%) patients. Two patients were undergoing
chemotherapy (FOLFIRI and R-CHOP), three patients
were using NSAIDs, and two were using steroids. A detailed
drug list is given in Table I
. Patient 2 declared that she was
using home-made stinging nettle extract twice daily for
weight loss. The medical history of patient 11 revealed
consumption of wild oyster mushrooms.
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|Table I: Clinicopathologic features of patients with ground glass-like hepatocytes.
Viral hepatitis serology, including hepatitis A, B, C, and E,
and autoimmune serology for ANA, ASMA, anti-LKM1,
AMAM2, anti-SLA, were negative. All of the cases had
elevated ALT and AST levels with a range of 107-754 U/L
and 41-693 U/L respectively. ALP levels were elevated in
3 of the 11 patients within a range of 179-1762 U/L. The
bilirubin level was mildly increased in one of these patients.
Follow-up data revealed that four patients died of their
malignant disease. The rest of the seven patients were
followed-up during a median period of 37 months (range
7-132 months). Patients showed resolution of elevated liver
enzymes within a median period of 50 days ranging from
26 to 150 days. Six of the seven patients were free of liver
disease, and control liver enzymes were within normal
limits. Only patient 8 showed a second peak of liver enzyme
elevation during a follow-up period of 33 months.
Histologic Features: Histologic evaluation showed
round eosinophilic inclusions, surrounded by a thin rim
of hepatocyte cytoplasm. Some of them had a clear halo
(possibly a retraction artifact) between the inclusion and cytoplasm. The nuclei were usually located at the periphery
of the cell (Figure 1A, C). These inclusions were positively
stained with PAS (Figure 1B). HBsAg immunostains
were all negative (Figure 1E). Phosphotungstic acidhematoxylin
stain for fibrinogen inclusions was negative in
all cases (Figure 1F). Ground glass-like hepatocytes were
distributed in a patchy-panlobular pattern in 6 (55%) of
the 11 patients. The rest of the patients (45%) showed a
zonal distribution, including 3 cases with periportal and 2
cases with centrizonal pattern. The most frequent histologic
changes associated with ground glass-like hepatocytes were
mild lymphocytic lobular inflammation with scattered
acidophil bodies (Figure 1D) and focal necrosis. Lobular
inflammation was found in 72% of the patients. Confluent
necrosis and bridging necrosis were not seen in any case.
Two cases (18%) showed mild zone 3 cholestasis and mild
ductular reaction. Mild portal lymphocytic infiltrate and
mild periportal fibrosis were present in one patient (9%).
Mild steatosis was present in one patient (9%). Histologic
features of steatohepatitis including ballooning and
pericellular (“chicken-wire”) fibrosis were not observed.
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|Figure 1: A) Liver biopsy showing pale eosinophilic, round ground glass-like inclusions in the periportal hepatocytes. Mild lobular
(arrow) and portal inflammation was noted (H&E; x200). B) PAS positivity in ground glass-like inclusions (PAS; x200). C) At higher
magnification, pale eosinophilic ground glass-like inclusions in the hepatocyte cytoplasm (H&E; x400). D) Ground glass-like inclusions
and scattered apoptotic hepatocytes (arrow) (H&E; x400). E) Ground glass-like inclusions are negative for HBsAg immunostain (arrow)
(IHC; x400) and F) Phosphotungstic acid-hematoxylin stain (arrow) (PTAH; x400).
Adaptive changes in hepatocytes similar to ground
glass hepatocytes have been described in patients with
anticonvulsant drugs, rifampicin, cholorpromazine, and
multi-drug use (5). Zubair et al. reported three patients with
PAS+ ground glass-like hepatocytes in an autopsy study of
bone marrow transplant patients. All patients were treated
with cyclophosphamide and methotrexate (3). Ground
glass-like change was also reported in a patient treated with mycophenolate, prednisone, and azothiopirine for
autoimmune hepatitis (6). Inclusions were reported to be
associated with hepatic outflow occlusion in another patient
(7). Two other case series of ground glass-like change were
reported in 2006 (4,8). Lefkowitch et al. reviewed 10 patients
with similar inclusions and they found that seven of their
patients were transplant recipients (5 with hematopoetic
stem cell transplant, 2 with liver transplant). All patients
had a history of multidrug use lasting several months.
Immunosuppressive drugs including mycophenolate,
tacrolimus, and steroids were commonly used by these
patients. Graft versus host disease (4 patients), acute
cellular rejection (2 patients), chronic hepatitis (1 patient),
and veno-occlusive disease (1 patient) were associated with
ground glass-like hepatocytes on histologic examination
of the liver biopsies (8). Wisell et al. found that nine
of the 12 patients were related to immunosuppression,
including transplantation, HIV infection, renal dialysis and
inflammatory bowel disease. All of the 12 patients were
using polypharmacotherapy, mostly including steroids
and tacrolimus (FK506)(4). Similarly, all three patients in
the series by Bejarano et al. were undergoing multidrug
medication including steroids and tacrolimus (9).
In summary of the above studies, PAS+ ground glass
inclusions have been mostly reported in immunosuppressed
patients on multidrug medications in a setting of
transplantation and immunosuppression. Transplantation
was not an etiologic factor in our patients. Also, in contrast
to previously published data, an underlying disease was
not found in 4 of our 11 patients. Clinical history revealed
medication use in nine (82%) patients including NSAIDs,
steroids, and chemotherapy. Stinging nettle extract and wild
oyster mushroom consumption were the possible causative
factors for PAS+ ground glass hepatocytes in two patients,
which is an unreported finding in English literature. Given
this finding, one might speculate that herbal preparations
and other alternative medicines may also lead to toxic effects
that may mimic all kind of injury on liver biopsy, including
ground glass change. Thus, herbal and mushroom toxicity
with ground glass change add new data about the histologic
spectrum of this entity.
There were no consistent liver function test results in the
literature review. A total of 25 patients (52%) from three
reported case series showed only mildly elevated enzymes
(4,8,9). All of the cases in our series were found to have
elevated ALT and AST levels. However, ALP levels were
also elevated in 3 of the 11 patients. Follow-up data revealed
four patients in this series who died of malignant disease.
The rest of the seven were followed-up during a median period of 37 months (range 7-132 months). Patients
showed resolution of elevated liver enzymes in a median
period of 50 days, ranging between 26-150 days. Most of
our patients were free of liver disease, and control hepatic
enzymes were within normal limits. Only one patient
showed a second peak of liver enzyme elevation during a
follow-up period of 33 months. The clinical significance
of ground glass-like hepatocytes is unclear; however, our
patients without malignant disease displayed an indolent
course, not associated with severe liver disease. Thus it
seems that abnormal liver test results were mostly related
to the accompanying disorder rather than ground glass-like
The histological distribution of the ground glass-like
inclusions in previous reports as well as our study varies
from case to case. Panlobular-patchy distribution was the
most frequent pattern in our series similar to Wisell et al.
(4). However, periportal predilection was also reported (8).
Other histological features of the liver biopsies included
mild lobular inflammation in most of our patients. Severe
acute hepatitis and chronic hepatitis with fibrosis were not
compatible with ground glass-like change. Mild cholestasis
and mild steatosis were seen in a minority of the cases.
The pathogenetic mechanism of PAS+ ground glass-like
hepatocytes related to immunosuppression as well as
medications and other alternative herbal or medicinal
agents remains unclear. It is hypothesized that ground glass
change in these settings is a result of glycogen accumulation
due to enzymatic inhibition in glucose metabolism (4).
Ground glass-like inclusion may thus reflect subcellular
hepatocyte injury with abnormal glycogen deposition
(10). Electron microscopy revealed glycogen accumulation
with degenerated organelles. Glycogen inclusions are
nonmembrane bound aggregates of beta glycogen granules
with endoplasmic reticulum. The inclusions resemble
polyglucosan bodies, which are considered ‘unbranched
equivalent of glycogen’ as possibly seen in GSD4. It remains
unclear whether it is an adaptive response to the induction
of hepatocytes by the medication (8,9,11).
Most of our patients with ground glass-like change
displayed an indolent course. A literature review and our
own series showed that the most likely explanation for
the development of ground glass-like hepatocytes is the
medication/drug effect. Transplantation was not a causative
factor in this study, in contrast to previous data. Herbal
liver toxicity may also cause hepatocyte changes similar to
ground glass morphology.
The author thanks Dr. Linda Ferrell (University of
California, San Francisco) for the review and comments
that greatly improved the manuscript.
CONFLICT of INTEREST
The author declares no conflict of interest.
Concept, design, data collection or processing, analysis or
Interpretation, literature search, writing, and approval for
the study were made by KD.
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