bluuebunny/crossref_metadata_2025_split huggingface dataset:
2312 Using Serum Transaminase Ratios to Recognize Herpes Simplex Hepatitis
Authors: Kern Cody , Schaberg Kurt , Deep Kristy 
Published: October 2019

INTRODUCTION:
Herpes simplex virus (HSV) hepatitis is an uncommon cause of acute liver failure (ALF). HSV hepatitis accounts for less than 2% of all cases of viral ALF. The clinical presentation is non-specific including encephalopathy, leukopenia, and fever. Typical HSV skin manifestations are present in less than 50% of cases. Diagnosis is challenging due to the lack of timely and reliable serologic testing. Liver biopsy can help with diagnosis however is not always available. Reported mortality is 88% for untreated HSV hepatitis. Early treatment with acyclovir reduces mortality to 51%. Current guidelines recommend starting acyclovir if HSV hepatitis is suspected (1).

CASE DESCRIPTION/METHODS:
A 67 year-old female presented with a four day history of nausea, vomiting, diarrhea, and progressive weakness. On admission, she was hemodynamically stable with a fever of 102.8F. Physical exam revealed RUQ tenderness. No labial or genital lesions were present. Laboratory testing revealed WBC 2500 IU/L, platelets 108,000/mm3, AST 3038 IU/L, ALT 696 IU/L, ALP 181 IU/L, TB 0.2 mg/dL, and INR 1.5. Viral hepatitis serologies were negative. CT abdomen revealed a 4.9 × 3.7 × 3.5 cm enhancing lesion in the liver dome. Liver biopsy of lesion showed multifocal non-zonal massive necrosis consistent with HSV hepatitis. The patient was started on IV acyclovir at 7mg/kg/8hr on hospital day twelve for a total of fourteen days. The patient improved and liver enzymes normalized prior to discharge.

DISCUSSION:
A prior review of sixteen case reports described HSV hepatitis presenting with a hepatocellular liver injury pattern of AST significantly more elevated than ALT (2). This case presented similarly, with the AST:ALT ratio being nearly 5:1. Despite this pattern previously being recognized, it is not regularly described in review articles or practice guidelines. Early treatment with acyclovir lowers mortality of HSV hepatitis, yet there are no clear recommendations on when we should suspect HSV hepatitis. Clinicians should consider early empiric acyclovir for ALF when traditional viral hepatitis serologies are negative and give special consideration for hepatocellular liver injuries with significantly elevated AST:ALT ratios as this may represent a pattern for HSV hepatitis.
2313 Graft-versus-Host-Disease Following Liver Transplant
Authors: Stratton Leland , Wentworth Brian , Intagliata Nicolas M. 
Published: October 2019

INTRODUCTION:
Graft versus host disease (GVHD) is a rare, life-threatening complication of liver transplantation that may affect the skin, GI tract and bone marrow. Donor T-lymphocytes remaining in the transplanted graft primarily target the recipient causing organ injury. Presentation may be non-specific and mimic other post-transplant complications, leading to delay in diagnosis and a mortality rate of greater than 80%. There is no consensus regarding optimal management of GVHD in the setting of liver transplantation.

CASE DESCRIPTION/METHODS:
A 65-year-old male with a history of NASH cirrhosis underwent deceased-donor liver transplant. Induction therapy was given with basiliximab and solumedrol then immunosuppression was maintained with tacrolimus, mycophenolate mofetil (MMF) and prednisone. Three weeks post-transplant, diarrhea developed and MMF was dose-reduced. Given persistence of diarrhea, fever, neutropenia and bilateral lower extremity petechial rash, additional work-up was performed. Imaging revealed colonic inflammation and subsequent flexible sigmoidoscopy demonstrated diffuse inflammation in the sigmoid. Biopsies of the colonic mucosa and lower extremity skin rash were consistent with GVHD. Peripheral blood confirmed the presence of donor chimerism. The patient was started on empiric antibiotics for febrile neutropenia, received granulocyte stimulating factor for leukopenia, intravenous steroids, and oral budesonide. MMF was initially discontinued but later resumed at increased dose; tacrolimus was continued. The patient's condition continued to deteriorate with diffuse mucosal GI bleeding. He received antithymocyte globulin and etanercept but his illness progressed secondary to Enterococcus bacteremia leading to septic shock. The patient died 8-weeks post-transplant in the setting of multiorgan failure.

DISCUSSION:
While rare, GVHD after liver transplantation should be considered in patients with new onset, unexplained symptoms. By virtue of its rarity after liver transplantation, data are sparse and management decisions are challenging. This case illustrates the need for increased awareness and standardized treatment guidelines. Management decisions are currently based on small case series often with discordant strategies including increasing or decreasing immunosuppression exposure. Global registries and multicenter collaboration will be essential to increase knowledge and improve outcomes.
2314 Pyogenic Liver Abscess in the Setting of Recent Polypectomy
Authors: Thomas Mathew J. , Kilpatrick Dustin , Mohammed Suneel , Krogel Nathaniel 
Published: October 2019

INTRODUCTION:
Pyogenic liver abscess (PLA) is a bacterial infection of the liver parenchyma with reported mortality of 6-14%. Early detection is vital to reduce overall morbidity and mortality. Due variability in clinical presentation, a high index of suspicion is necessary to avoid delay in diagnosis and treatment. Intra-abdominal infections such as diverticulitis or pathologic conditions of the biliary tract are the most common etiologies of PLA but micro-perforations in the setting of recent polypectomy leading to bacterial seeding through the portal circulation may account as an under-reported precipitant.

CASE DESCRIPTION/METHODS:
A 63-year-old male with history of chronic alcohol abuse who was admitted to the ICU on broad spectrum antibiotics after developing acute respiratory failure requiring mechanical ventilation and septic shock. The patient had several days of vague abdominal pain which led to acute worsening with encephalopathy. Initial evaluation in the ED revealed temperature of 106.2 and laboratory results revealed WBC 27.8, lactic acid of 3.6, procalcitonin level 52 ng/mL, alkaline phosphatase 131, AST 90, and ALT 65. CT of the abdomen and pelvis revealed multiloculated cystic mass in the dome of right liver measuring 8.6 cm × 8.1 cm x 7.2 cm. It was noted that patient had underwent a screening colonoscopy approximately three weeks prior to admission and multiple polyps were removed with a hot snare in the ascending, descending and sigmoid colon. Admission blood cultures revealed polymicrobial bacteremia and grew streptococcus and E. coli. Due to concern for underlying liver abscess from recent bacterial seeding from polypectomy, patient underwent IR guided drainage and placement of drain which relieved purulent fluid that cultures eventually became positive for Streptococcus intermedius. Despite appropriate antibiotic coverage, patient had persistent fevers and required transfer to hepatobiliary service for definitive surgical management. Patient underwent hepatic lobectomy and laparoscopic marsupialization of the liver abscess with dramatic improvement of fever curve and leukocytosis.

DISCUSSION:
PLA in the setting of recent colonoscopy is a known phenomenon, however the incidence is unclear. As colorectal cancer screening rates continue to increase in practice, awareness of the development of PLA in the setting of immunocompromised patients must be highlighted. Patient counseling on this potentially fatal complication should occur especially to immunocompromised patients.
2315 Early Detection and IR Intervention in a Case of Fulminant Budd-Chiari Syndrome
Authors: Rezaie Aida , Ahmed Shifat , Al-Jashaami Layth , Patel Nayan 
Published: October 2019

INTRODUCTION:
Budd-Chiari syndrome (BCS) is a relatively rare cause of abnormal LFTs, and infrequently progresses to fulminant hepatic failure. BCS requires a high degree of suspicion and can be easily confused with other causes of rapidly worsening liver enzymes. We present a case that illustrates successful management of fulminant hepatic failure by interventional radiology (IR) guided thrombolysis and thrombectomy, followed by TIPS placement in a rapidly decompensating 34-year-old woman who initially presented with mildly abnormal LFTs.

CASE DESCRIPTION/METHODS:
A 34-year-old white woman with past medical history of acid reflux, and family history of venous thromboembolism, presented to an outside hospital with a 5-day history of nausea, vomiting, diarrhea. She was subsequently was transferred to our facility for a higher level of care after worsening liver function testing and mentation. Patient had reported 5 days of epigastric tenderness, nausea, and abdominal distension prior to admission. Her LFTs continued to worsen, and clinically, she became progressively more hypotensive and tachycardic (BP 74/44, HR 112) requiring vasopressor support without significant improvement in her vital signs. Within 48 hours, she had acute onset of ascites and worsening encephalopathy. On arrival to our facility, she underwent CT abdomen/pelvis with and without IV contrast showing complete thrombosis of the right, left, and middle hepatic veins. Her liver function and transaminases continued to worsen prompting IR intervention. She underwent IR-guided thrombolysis and thrombectomy and TIPS with pre- and post- intervention pressures showing marked improvement in the transhepatic pressures (Table 1). (Pre- and post-intervention imaging in Figures 1 and 2). As part of her hypercoagulable workup, she was found to be deficient in protein C activity (46%). She had no OCP use for over 10 years.

DISCUSSION:
It was later discovered that patient’s mother had a history of saddle pulmonary embolism and other maternal relatives have had a pro-coagulative history, most of whom presented with significant lower extremity DVTs. This case illustrates that a high clinical suspicion is needed to make an early diagnosis of BCS, which can lead to early intervention and minimize the need for emergent liver transplantation. This case emphasizes the significant of a thorough history, and particularly a family history of venous thromboembolism.
2316 Gangrenous Cholecystitis and Revelation of Gallbladder Metastasis From Primary Breast Cancer
Authors: Minupuri Arun , Gudipally Sindusha , Nair Jayamohan , Walli Omar , Modi Simple , Salas Noain Jesus M. 
Published: October 2019

INTRODUCTION:
Breast cancer metastasis seeds various organs in the body by gaining access to blood and lymphatic vessels. The preferential sites involve the lung, liver, bone, and brain, and symptoms usually compromise of chest pain, cough, shortness of breath, abdominal pain, and joint pain. Metastasis to the gallbladder is of a rare phenomenon, and here in our case report we present an unusual discovery of gangrenous cholecystitis through diagnostic laparoscopy; with eventual histopathological findings revealing metastatic primary breast cancer to the gallbladder.

CASE DESCRIPTION/METHODS:
A 59-year-old African American female presented to our institution with 1-day history of abdominal pain. The abdominal pain is of sudden onset, mainly located in the right upper quadrant, sharp/stabbing in nature, intermittent, radiating towards the right flank and was associated with non-bilious/non-bloody vomiting. Medical history included hypertension, hyperlipidemia, myocardial infarction X2, and notably a recent diagnosis of metastatic breast cancer. She was diagnosed 2 months prior to admission with T4N3M1 breast cancer. Labs were significant for AST 89, ALT 68, Alk Phos 178, and albumin 3.4. CT of the chest and abdomen was done which showed re-demonstration of metastatic breast cancer along with marked gallbladder wall thickening without obvious gallbladder calculi. A HIDA scan was performed which excluded cholecystitis. Patient was admitted and was started on intravenous fluids, antibiotics, and pain medications. General surgery was consulted, and decision was made for diagnostic laparoscopy. Laparoscopy revealed perforated acute gangrenous cholecystitis, leading to the removal of gallbladder along with appropriate cleansing of the abdomen. Histopathological examination of gallbladder shows tumor cells positive for GATA3 and ER (greater than 90%) [Figures 1 and 2]. Post operatively patient had no complications and was successfully discharged with close outpatient follow up.

DISCUSSION:
Metastasis (mets) to the gallbladder is rare, and from breast primary it is considered an extremely rare occurrence. In our case report, we see a patient with history of breast cancer developing symptoms of sudden onset right upper quadrant pain with vomiting and liver derangements. Treatment plans differ for primary gallbladder cancer vs mets to gallbladder; as histochemical testing is the key to accurate diagnosis. Hence, for appropriate treatment plans, clinicians should be aware of unusual presentation of metastatic breast cancer.
2319 A Case of Cryptogenic Liver Abscess in a Young Uncontrolled Diabetic
Authors: Mahmood Sharmeen , Kaur Randeep , Sayf Alaa Abu 
Published: October 2019

INTRODUCTION:
Pyogenic liver abscess (PLA) is a rare complication of Diabetes Mellitus, usually seen in older adults who have had diabetes for many years. There is little information regarding the effects of glycemic control on the characteristics of PLA in diabetic patients. Actinomycosis is an infrequent invasive bacterial disease with indolent and non-specific presentation, therefore diagnosis is quite difficult to make for clinicians. Here, we report an uncontrolled diabetic patient who developed cryptogenic Actinomyces odontolyticus bacteremia and concurrent polymicrobial liver abscess.

CASE DESCRIPTION/METHODS:
A 41-year-old male with a history of uncontrolled Diabetes Mellitus Type 2, presented with severe, dull, epigastric pain. He was found to be in septic shock and diabetic ketoacidosis, requiring admission to the medical intensive care unit. Initial laboratory tests showed a white blood cell count of 16,800/mm3 (87% neutrophils), bicarbonate 14mmol/L, AST 147, ALT 126, alkaline phosphatase 193, beta hydroxybutyrate 5.04, and anion gap 17. HIV testing was negative. Hemoglobin A1c was 13%. A computed tomography (CT) image of his abdomen revealed a 7cm gas containing lesion in the left hepatic lobe concerning for hepatic abscess. He was started on empirica vancomycin and piperacillin/tazobactam and subsequently underwent CT-guided pigtail catheter insertion for drainage of the abscess. Microbiological examination of the drainage revealed polymicrobial pus including rare actinomyces. His blood cultures revealed actinomyces odontolyticus. He improved hemodynamically and repeat blood cultures were negative. He was discharged on IV Penicillin G and Metronidazole with duration dependent on resolution of abscess. Once infection is resolved, he will undergo colonoscopy and dental examination to identify possible source for infection.

DISCUSSION:
The incidence and morbidity of patients with PLA and diabetes has recently increased. Hyperglycemia can promote bacterial growth in tissues, and metabolic disorders impact the gastrointestinal tract. Diabetes can also promote infection through reduced immunity, neutrophil chemotaxis, mononuclear phagocyte activation, and opsonization. Actinomyces Odontolyticus is rare, especially in the absence of other pathology, and many conditions have been described as a possible initiating event including diverticulitis, appendicitis or peptic ulcer disease. A multi-team approach is always recommended when disseminated actinomycotic infection is observed.
2321 Treatment of Hepatitis C in an Immunosuppressed Patient With Malignancy
Authors: Coburn Elliot , Drinane Mary 
Published: October 2019

INTRODUCTION:
The prevalence of hepatitis C (HCV) is estimated to be 1-1.5% in patients with cancer. Direct-acting antivirals (DAA’s) have been shown to be a safe and effective option for treatment of HCV in patients with concurrent malignancy. However evidence for the use of DAAs in combination with b-cell depleting agents is lacking. We present a complicated case of a patient with lymphoma and HCV, who was treated simultaneously with rituximab and DAA therapy.

CASE DESCRIPTION/METHODS:
A 57-year-old male presented with recurrent angioedema due to acquired C1 esterase deficiency. Workup led to a bone marrow biopsy showing marginal zone lymphoma (MZL). He was pulsed with dexamethasone with plan to start rituximab. HCV screening was negative. Just prior to rituximab dose, he was found to have jaundice. Labs revealed an AST 2195, ALT 4828, total bili 5.1, alk phos 120, platelets 9k. Liver ultrasound showed hepatomegaly. He reported recent high risk sexual behavior. Initial workup revealed negative hepatitis A/B/C antibodies, ferritin 10.6k, negative autoimmune workup, and an HCV viral load of 31 million copies. His liver tests improved and he was seen in clinic where liver elastography showed a kPa of 17.7 (IQR 21%). He was started on a 12-week course of glecaprevir/pibrentasvir. Follow up HCV antibody was positive three weeks later. His clinical course was further complicated by ITP treated with IVIG, dexamethasone, rituximab and ultimately splenectomy. Course was also complicated by renal failure due to secondary minimal change disease and neuropathy due to AIDP/CIDP. He received additional dexamethasone and IVIG for these conditions. One month later he completed DAA therapy, LFTs normalized, and his HCV viral load was < 12. Two days after completing HCV therapy he was admitted to the ICU with septic shock of unclear etiology, ultimately resulting in death.

DISCUSSION:
Our patient’s workup was suggestive of acute HCV given initial negative antibody with eventual seroconversion. A 12-week course of glecaprevir/pibrentasvir was chosen, as there was uncertainty regarding whether or not cirrhosis was present. Aggressive immunosuppression was given concomitantly for the MZL, as well as other immune-mediated diseases. His sepsis-related death was felt to be due to prolonged hospitalization in an immunosuppressed state rather than DAA therapy. Larger scale studies are needed to further inform optimal treatment of HCV in patients receiving immunosuppressive therapy, in the setting of malignancy.
2323 Bone Metastasis as Index Presentation of Hepatocellular Carcinoma
Authors: Then Eric O. , Ofosu Andrew , Gayam Vijay , Maddika Srikanth , Chaudhri Ali , Gaduputi Vinaya 
Published: October 2019

INTRODUCTION:
Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver, and the fifth most common cancer worldwide Extrahepatic mestastasis rarely occurs in patients with early course HCC. Bone metastasis as the initial presentation of HCC is even more rare. Here we present an unusual case of Bone metastasis to the ninth rib as the index presentation of HCC.

CASE DESCRIPTION/METHODS:
The patient is a 60 year old male with a medical history of hypertension, hepatitis C virus, hyperlipidemia, rheumatoid arthritis and chronic obstructive pulmonary disease who presented to the emergency department complaining of right upper quadrant pain for one week. Physical exam was notable for tenderness over the patients right ninth rib. The rest of the physical exam was unremarkable. Notable laboratory workup included a complete blood count and comprehensive metabolic panel within normal limits. Notable imaging included a computed tomography of the abdomen showing a mass over the ninth rib with multiple foci in liver. The next day an alpha fetoprotein (AFP) level was ordered and returned elevated at 1139.0 ng/ml. Other tumor markers including carcinoembryonic antigen (CEA), carbohydrate antigen 19 9 (CA 19 9) and prostate specific antigen (PSA) were within normal limits. Interventional radiology was then consulted and performed a biopsy of the ninth rib mass which showed metastatic carcinoma with a primary of hepatocellular malignancy. This diagnosis was supported by positive staining with Hep-Par 1. Following this diagnosis the oncology service was consulted and recommended palliative radiotherapy to the ninth rib and starting treatment with Sorafenib. The patient was then discharged with pain medications and follow up appointments.

DISCUSSION:
Common risk factors for the development of HCC include Hepatitis B, Hepatitis C, Aflatoxin exposure, and cirrhosis of any cause (including alcohol). The most common sites of extra-hepatic metastasis of HCC are lung, lymph node, musculoskeletal, and adrenal gland. Isolated bone metastasis of HCC is rare occurring in only 9.5% of patients. Symptoms associated with HCC include right upper quadrant pain, jaundice and ascites in more advanced cases. Treatment of metastatic HCC to bone includes chemotherapy and targeted radiotherapy. More recently Bisphosphonates have also been shown to have success.
2331 Post-Infantile Giant Cell Hepatitis Leading to Severe Acute Liver Injury in Chronic Lymphocytic Leukemia (CLL): Progression of CLL vs. Drug Induced Liver Injury (DILI)
Authors: Saeed Naba , Warrier Govind , Likhitsup Alisa , Hassan Ammar , Choi Eun-Young K. , Conjeevaram Hari 
Published: October 2019

INTRODUCTION:
Post-infantile giant cell hepatitis (PIGCH) is a form of hepatocyte degeneration, triggered by noxious injury. Underlying etiologies are autoimmune, drug-induced, virus mediated and miscellaneous e.g. sickle cell, CLL, post-transplant. While only occurring in 5 per 100,000 adults, when present, rapid progression to liver failure can result in a 50% mortality rate.

CASE DESCRIPTION/METHODS:
A 76 yo lady with a history of anemia, remote breast cancer in remission, and CLL (not on treatment), presented with a 3-week history of fatigue, nausea and jaundice following a 5-day course of azithromycin and prednisone (20 mg OD), and one dose of ceftriaxone, for acute bronchitis. Exam revealed jaundice and abdominal distension. Admission labs: AST 4233U/L, ALT 3175U/L, ALP 187IU/L, total bilirubin 9.4 (7.1 direct) mg/dl, sodium 131mEq/L, BUN 27, Cr 0.7 mg/dl. INR 1.4. WBC 68.3/µL, hemoglobin 8.2 g/dl, platelets 233/µL. CT Abd/Pelvis without contrast: mild periportal edema, with enlarged liver, otherwise normal. Workup for viral hepatitis, other viruses and autoimmune serologies was negative, other than ANA titer of 1:640. Tox screen and mass spectrometry were negative. Given worsening liver injury, liver biopsy was obtained, which had active hepatitis with giant cell transformation, patchy necrosis, and CLL in portal areas (Figure 1). The patient was recommended high-dose prednisone, but she deferred therapy. Labs were followed closely, with remarkable improvement within a few days. She was discharged on ursodiol. On follow-up 2 months later, a mild transaminitis was persistent, so prednisone therapy was started with subsequent resolution of her hepatitis. However, subsequent imaging revealed development of cirrhosis.

DISCUSSION:
Treatment of PIGCH is dependent on underlying etiology, with autoimmune pathology having the best prognosis described in the literature versus variable courses for drug induced PIGCH, once the offending agent is stopped. In our patient, the trigger for giant cell transformation was suspected to be drug induced liver injury, from treatment with azithromycin/ceftriaxone. Interestingly, CLL itself can spontaneously transform to PIGCH as well, with treatment of CLL improving prognosis. Our patient did not want immunosuppressive therapy initially. Although her acute liver injury spontaneously improved, she did develop cirrhosis as a long-term complication. PIGCH must be aggressively treated/monitored to prevent life-threatening fulminant hepatic failure, or subsequent cirrhosis.