To the Editor. —
The thoughtful review by Sherman1 provides a useful approach to the practicing physician. He makes the recommendation that elevations of alanine aminotransferase levels less than twofold not be pursued even if they persist for 6 weeks or more. Although this appears a useful strategy in general, some forms of liver disease may benefit from a slightly different approach. He fails to include environmental and occupational exposures in his list of potential causes. This is a common omission; several recent reviews2-4 of fatty liver disease have similarly failed to suggest hepatotoxin exposure as a potential cause of elevated alanine aminotransferase levels in practice. Outbreaks of occupational liver disease are, nevertheless, well described.5,6,6 A case-control study7 of randomly occurring fatty liver disease has similarly suggested that hepatotoxin exposure may be an important risk factor. Four further cases with less than twofold elevations of alanine
Hodgson MJ. Alanine Aminotransferase in Clinical Practice. Arch Intern Med. 1992;152(1):208. doi:10.1001/archinte.1992.00400130196033
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