bluuebunny/crossref_metadata_2025_split huggingface dataset:
3178 Augmentin-Induced Liver Injury in a Patient With Progressive Familial Intrahepatic Hepatic Cholestasis (PFIC)
Authors: Farooq Saba , Einstein Micheal 
Published: October 2019

INTRODUCTION:
We are reporting a case of drug induced liver injury (DILI) within 48 hours of Augmentin administration in a patient with progressive familial intrahepatic cholestasis.

CASE DESCRIPTION/METHODS:
27-yo female with PMH of severe ATP8B1 protein deficiency, PFIC S/P hepatojejunostomy with external biliary diversion, not a transplant candidate due to psychosocial issues, presented with epigastric pain, vomiting and constipation. Home meds included hydroxyzine, questran and rifampin. On admission vitals were BP: 110/59, pulse: 107, temp: 98.3, O2 sat: 100% on RA. Physical exam was unremarkable except icteric sclera. Labs showed WBCs: 19.1, H&H: 14.1/41.4, PLT: 187, Total Billi: 17.9, AST/ALT/ALP of 566/398/172, normal BMP except Bicarb: 15. INR: 1.8, lipase 25, UA negative for infection. CT Abd/pelvis W/contrast did not show any acute hepatobiliary pathology, except endometrial prominence with some fluid. Rifampin was stopped, aggressive bowel regimen, IV hydration and IV antibiotics including Unasyn and doxycycline were started. Fuid from endometrial cavity was cultured. Pt's abdominal pain improved as constipation resolved. Antibiotics were switched to Augmentin for presumed endometrial infection. LFTs started rising within 48 hrs of augmentin administration. Peak LFTs were T.Billi/AST/ALT/ALP:21.5/762/528/132. Complete laboratory evaluation included negative serologies for hepatitis, A, B, C, EBV, CMV and negative assays for ANA, AMA, ASMA. Augmentin was stopped. Two weeks after discontinuation of Augmentin, patient's LFTs started to improve.

DISCUSSION:
DILI is a well-recognized complication of Augmentin use and multiple cases have been reported. Associated mortality can be as high as 10%, and thus prompt recognition and removal of the offending agent is of critical importance. In our patient, while systemic infection and rifampin use were other possibilities for liver injury however, worsening and improvement in LFTs correlated with Augmentin administration and discontinuation. Moreover, dose of rifampin was not changed for over a year. Several risk factors have been identified for DILI including older age, genetic determinants, preexisting liver disease and properties of certain medications. Our patient had PFIC and Augmentin use caused liver injury within 48 hrs of administration as compared to other case reports where latent period of Augmentin induced liver injury varied from days to weeks. In both DILI and PFIC, treatment options are very limited thus Augmentin should be avoided.
3186 Fatal Case of Acetaminophen Toxicity in a Young Female Patient
Authors: John Jaison , Al-Douri Abdul , Bhakta Meera , Kapadia Anupama 
Published: October 2019

INTRODUCTION:
Acetaminophen is the most common cause of acute liver failure (ALF) in the United States. We report a fatal case of acetaminophen overdose after both delayed presentation for treatment and transplant evaluation in a non-liver transplant academic center.

CASE DESCRIPTION/METHODS:
An 18-year-old woman presented to the emergency department (ED) after attempting suicide by overdosing on acetaminophen. She ingested 48 of the 500 mg tablets (24-gram total dose) 18 hours prior to arrival to the ED. Her only symptom was back pain. Her medical history was significant for depression and three prior suicide attempts by acetaminophen overdose. Her mental status declined over the next few hours to the point of becoming non-verbal and mildly drowsy. On physical exam, patient was tachycardic and had self-inflicted scars to her forearms. Initial labs were significant for white blood cell count of 22,300 cells/mm3, bicarbonate of <5 mmol/L (21-31), glucose 59 mg/dL (70-110), alkaline phosphatase 91 units/L (42-121), aspartate aminotransferase 479 units/L (5-34), alanine aminotransferase acetaminophen 228 mcg/mL (<30), PT 27 seconds (9.4-12.5 sec), INR 2.5, and ammonia 147 mcmol/L (18-72). Venous blood gas revealed pH 6.819, pCO2 29 mmHg (39-51), pO2 51 mmHg (30-50), calculated bicarbonate of 4 mmol/L, and lactate of 14 mmol/L (0.5-2.20). Table 1 highlights changes in laboratory values during admission. The patient was admitted to the ICU, started on N-acetylcysteine (NAC) and bicarbonate infusions, and had urgent renal and general gastroenterology consultations. 48 hours after admission the patient was intubated due to deteriorating mental status and seizure activity. It was suspected that she was having cerebral edema and was emergently transferred to a liver transplant center. Ultimately, she did not undergo transplant and died from complications of ALF.

DISCUSSION:
Acetaminophen overdose carries a high risk of ALF and mortality. Survival depends on early treatment as high doses can overwhelm liver metabolism resulting in hepatotoxicity by N-acetyl-p-benzoquinoneimine (NAPQI). Treatment from time of ingestion was delayed in this case due to the patient's delay in seeking care. Transfer to transplant center was delayed due to lack of insurance, history of multiple attempts that affected her liver transplant candidacy, and under-appreciating risk of developing ALF. This case highlights the fatal complications of acetaminophen overdose, and underscores the importance of emergent transfer to transplant center.
3191 Two Cases of False Positive Hepatitis B Surface Antigen With Positive Hepatitis B E-Antigen
Authors: Shah Niraj J. , Paine Elizabeth , Burton Mary 
Published: October 2019

INTRODUCTION:
Hepatitis B surface antigen (HBsAg), is a HBV surface protein particle that indicates current HBV infection. Hepatitis B e Ag (HBeAg) indicates active HBV replication. HBsAg, is a sensitive test, that utilizes anti-HBs to bind to and detect surface antigens to HBV. Any weakly positive HBsAg test needs to be further confirmed using a neutralization test to confirm infection. Below we have briefly described two cases of unusual hepatitis B serology.

CASE DESCRIPTION/METHODS:
Case 1- 78-year-old Caucasian male, with CKD, was worked up for hepatitis B as he was being considered for dialysis. Initially, on history he had provided positive risk factors (use of illicit drugs and multiple sexual partners) for hepatitis B infection. He denied any recent vaccinations. The transaminases were within normal limits. The hepatitis B surface antigen (HBsAg) was positive. However, the neutralization test was not confirmatory on two occasions. He had hepatitis B e Ag (HBeAg) positive as well. He was negative for Hepatitis B surface antibody (HBs Ab), hepatitis B core total antibody (AntiHBc-T), hepatitis B core IgM (AntiHBc- IgM) and HBV e antibody (anti-HBe). The hepatitis B viral DNA was also negative. The patient was negative for hepatitis C and HIV. The results were similar 6 months later. Case 2- 65-year-old Caucasian male, with psoriatic arthritis, was screened for hepatitis B as part of his management for psoriatic arthritis and was found to have a reactive HBsAg. He had no defined risk factors for HBV. His initial HBsAg was negative 7 years back. His hepatitis B serological profile was similar to the first patient.

DISCUSSION:
Heterophile antibodies could explain why the confirmatory test for HBsAg, after neutralization, was negative. Our patient had not received the HBV vaccination. Also, it does not explain why the HBeAg would be positive. HBsAg “escape” mutants are generally considered when the HBeAg and/or the HBV DNA is positive, in chronic HBV infection, which was not our case. Though we have come a long way in improving diagnostic laboratory capabilities, we still require better assays to accurately diagnose HBV. Present HBV guidelines do not define our case. We were unable to identify similar case reports. We continue to monitor our two patients, for if we decide to start them on hemodialysis (our first patient) or initiate immunosuppressive agents (for our second patient), the challenges of HBV reactivation are real.
3194 Sneaky Abscess-Ion: A Pyogenic Liver Abscess Masquerading as the Flu
Authors: Likhtshteyn Michelle , Arroyo-Mercado Fray , Iqbal Sadat , Ho Johnson , Botti Evan , Kim Joseph K. , Masub Natasha , Cobb Kaycie 
Published: October 2019

INTRODUCTION:
Pyogenic liver abscess (PLA) is due to leakage of intra-abdominal contents with hepatic spread via the portal circulation. The incidence of PLA is estimated to be 2.3 cases per 100,000 people with higher rates among men than women [1]. We present a case of a 58-year-old male with no abdominal tenderness, risk factors, or recent travel history, who was found to have a 3 cm liver abscess growing Klebsiella Pneumoniae (K.pneumoniae).

CASE DESCRIPTION/METHODS:
The patient is a 58-year-old African American man with a medical history of HTN and HLD who presented with 3-day history of muscle aches, subjective fevers, and chills. Initially the patient was suspected to have a flu and was treated with fluids and antipyretics. He was noted to have transaminitis (AST/ALT: 202/139), however denied nausea or abdominal pain. An ultrasound demonstrated a complex cystic mass in the right lobe of the liver, and a CT Abd/Pelvis showed a 3.2 × 3.1 × 2.3 cm heterogeneous hypodense mass in segment V. The patient remained febrile with a Tmax of 102 and began to develop severe RUQ on day two of admission. The patient was maintained on Zosyn 3.375g q6h and initial blood cultures grew gram negative rods. Patient tolerated IR drainage of liver abscess yielding 10cc pustular fluid with subsequent resolution of fever. Both blood and liver cultures grew pan-sensitive K.pneumoniae.

DISCUSSION:
PLA commonly develops as a complication of biliary tract disease in 40% of cases [2]. In the United States, K. pneumoniae is the predominant pathogen causing PLA; isolated in greater than 60% of monomicrobial and polymicrobial PLA [3]. Groups who are susceptible to infection with K. pneumoniae include patients of Asian ethnicity, diabetics, and those with antibiotic use [2]. Our patient did not have any risk factors for PLA; he had minimal medical history and only took amlodipine on presentation. Common symptoms of PLA include fever, right upper quadrant abdominal pain, and rarely jaundice [1]. Our patients' initial presentation was consistent with a flu like prodrome; however, his transaminitis suggested an underlying hepatic process. While a PLA was unlikely on admission, worsening sepsis and new abdominal pain elucidated the diagnosis. K. pneumoniae PLA can lead to disseminated infections including meningitis; the identification and drainage of an abscess early in the hospital course can alter a patients' mortality. While PLA is rare, it should still remain on the differential diagnosis for septic patients.
3200 A Rare Case of Hepatitis B Association With Sarcoidosis and Treatment Challenge With Immunosuppressive as Resulting in Colonic Histoplasmosis
Authors: Jiyani Rucha , Patel Pinakin , Patel Saumil 
Published: October 2019

INTRODUCTION:
There have been documented cases reflecting association between Hepatitis C virus (HCV) and sarcoidosis but it is very interesting as in this case that we discussed about association of Hepatitis B virus (HBV) and sarcoidosis, presenting with vague symptoms and confirmed with liver biopsy and immunologic markers. Further challenging is treatment with immunosuppressive medication leading to colonic histoplasmosis.

CASE DESCRIPTION/METHODS:
58 year old Indian female with past medical history of cirrhosis secondary to HBV diagnosed six months ago, hypertension and diabetes mellitus 2 presented with bilateral pedal edema, anorexia and mild epigastric discomfort. She has been started on Entecavir since diagnosis six months ago. Patient denied any significant surgical, social and family history. Ultrasonography Liver revealed hepatosplenomegaly and mesenteric lymphadenopathy. 21.3kPa liver stiffness on elastography and HBV level 83. Liver biopsy showed multiple non caseating granulomas consist of Langerhans cell in parenchyma and portal tract, associated with moderate inflammation. Chest CT scan showed upper and middle lobe fibrosis of lung, diagnosis further confirmed with elevated Angiotensin converting enzyme. She was started on prednisone; within 3 months she experienced weight loss, diarrhea and fever. Colonoscopy was done after CT abdomen showed mural thickening of ascending colon and terminal ileum, which on biopsy confirmed Histoplasmosis as described in Figure 1. Prednisone stopped and patient treated with Hydroxychloroquine, amphotericin followed by itraconazole. Patient improved symptomatically and repeated colonoscopy was normal.

DISCUSSION:
As in this report, studies are scarce to prove association. However; reasonably assumed that the alterations in the pool of cytokines and immune cells caused by HBV infection may have a vicious influence on the immune regulation and can be a trigger for granuloma. Further studies can impact future era for better understanding in pathophysiology of sarcoidosis and HBV correlation and treatment options.
3209 Mesenteric Vein Thrombosis: An Unusual Cause of Small Bowel Obstruction
Authors: Boppana Vaishnavi , Paleti Swathi 
Published: October 2019

INTRODUCTION:
Mesenteric venous thrombosis (MVT) is an uncommon cause of acute to sub-acute abdominal pain. Early recognition and treatment have survival implications.

CASE DESCRIPTION/METHODS:
A 42 year-old male with past medical history of hypertension and obstructive sleep apnea presented with 3 weeks of worsening abdominal pain, nausea and vomiting. Physical exam revealed diffusely tender abdomen with mild guarding, no rebound tenderness and normoactive bowel sounds. Pertinent labs on admission included an elevated white count of 13.5 K/mm3 and lactate of 2 mmol/L. A non-contrast CT abdomen demonstrated small bowel loops with abnormal wall thickening and associated inflammatory changes. He was started on broad spectrum antibiotics for enteritis, however he had worsening abdominal pain and an abdominal x-ray revealed small bowel obstruction. Patient was made NPO and conservatively managed with IV fluids. His hospital course was complicated by fever of 100.8 F and leukocytosis of 26.3 K/mm3 Infectious work up was unremarkable and a CT abdomen with contrast revealed thrombosis of main portal, superior mesenteric and splenic vein. Hypercoagulable workup resulted in decreased Protein S activity (1779X) and Factor II heterozygosity (prothrombin G20210A mutation).

DISCUSSION:
MVT accounts for 6%–9% of all the cases of acute mesenteric ischemia. Most common presenting symptom is abdominal pain which occurs in 91–100% of the cases followed by nausea, vomiting and melena. Associated portal venous thrombosis can be seen if the disease originates in the major veins instead of the small vena rectae. Young patients without known risk factors for venous thromboembolic (VTE) and thrombosis in unusual sites such as portal, mesenteric and cerebral veins should be evaluated for thrombophilias. Approximately 20-40% of patients have previous history of deep vein thrombosis or may have a pre-existing hereditary hypercoagulable state such as protein C deficiency, protein S deficiency, anti thrombin III deficiency, factor V Leiden deficiency, or antiphospholipid syndrome. In general, outcomes in MVT are better when compared to arterial thrombosis with mortality of 44% as compared to 66–89% respectively. Studies have shown that early use of heparin has been associated with improved survival. Early recognition of MVT and treatment with anti coagulation has led to non-surgical treatment and improved outcomes.
3211 An Incidental Duodenal Lymphangioma Presenting as Diarrhea
Authors: Pagan Andrea , Mony Shruti , Gill Jeffrey , Arroyo Yadis , Bertran-Rodriguez Carlos E. 
Published: October 2019

Introduction:
The small bowel is a rare site for neoplasia and only account for over 3% of the cases in the digestive tract. Lymphangiomas are benign tumors formed by dilated lymphatic channels that occur more commonly in the neck and axillary regions. Duodenal lymphangiomas are extremely rare in the adult population. It s thought to be a benign congenital malformation of the lymphatic vasculature that is able to grow to form a mass lesion. Their clinical presentation ranges from asymptomatic to obscure bleeding, small bowel obstruction, intussusception or even volvulus. We present a case of a duodenal lymphangioma presenting with chronic abdominal pain and diarrhea.

CASE DESCRIPTION/METHODS:
A 37-year-old male with no significant past medical history presented with chronic diarrhea, constipation and abdominal discomfort for 3 years. Physical examination and laboratory data were in the normal limits. Remainder of his infectious and inflammatory workup for diarrhea was negative. He underwent endoscopy which revealed a 1-cm polypoid submucosal lesion in the post-bulbar area. Multiple deep bites-on-bite biopsies were obtained from the lesion. Histological examination showed dilated lymphatics with reactive epithelial changes, consistent with Lymphangioma. During the follow up visit the patient referred improvement of the presenting symptoms.

DISCUSSION:
Lymphangiomas of the duodenum are a very rare lymphatic system tumor. The clinical presentations are usually variable and nonspecific and may mimic a variety of vague abdominal symptoms like abdominal discomfort, diarrhea, anorexia, nausea, and vomiting. These lesions typically exist as small incidental polyps; however, some of these tumors present as mass lesions capable of causing bowel obstruction, abdominal pain, and gastrointestinal bleeding. By endoscopic examination, they usually appear as a sessile or semi-pedunculated mass with smooth surface mucosa with lymphatic cystic dilatation with a whitish granular appearance. These benign tumors require treatment if they are accompanied by symptoms and complications such as infection, obstruction and hemorrhage. Endoscopic unroofing or polypectomy has become the treatment of choice for small to intermediate lymphangiomas. Physicians must thus be cognizant of the differentials for small bowel nodules in order to avoid unnecessary surgical interventions.
3217 Intussusception in a Patient With Marijuana Use: Coincidence or Possible Correlation?
Authors: Khan Zarak H. , Paul Jonathan R. , Singh Tejveer , Jarodiya Vijay , Khan Tahir , Alam Ariful , Korpole Pranay R. , Rai Raveen 
Published: October 2019

INTRODUCTION:
“Intussusception” is a term initially used by the Scottish surgeon, Dr. John Hunter in 1789 which means invaginating or telescoping. It is caused by any condition that disrupts the normal physiological mechanism of intestinal peristalsis. Intussusception in adults is rare with incidence of 2-3 cases per population of 1000000 annually. The most common cause of intussusception in adults is neoplasms.

CASE DESCRIPTION/METHODS:
22-year-old female, with multiple past episodes of abdominal pain and vomiting, presented with one day duration of sudden onset worsening abdominal pain, vomiting and diarrhea. The stools were black but without tarry clots or frank blood. She also had four episodes of non-bilious and non-bloody emesis. Of note, she had more than one year history of extensive marijuana use. Upon presentation, her vitals were unremarkable. Physical exam was pertinent for diffuse abdominal tenderness without guarding or rebound. Initial labs were unremarkable except for an elevated lactic acid level (4.6 Mmol/L). Pregnancy test was negative. Patient received anti-emetics, proton pump inhibitor and IV fluids. She then underwent a CT scan of the abdomen and pelvis which revealed a small bowel intussusception in the left hemiabdomen. She was made NPO and subsequently underwent both upper endoscopy and colonoscopy which were normal. She was treated conservatively with bowel rest, anti-emetics and IV fluids. She gradually improved with resolution of symptoms on day four of hospital stay. Her intussusception had resolved on a follow up small bowel series. She was discharged home with outpatient Gastroenterology follow up.

DISCUSSION:
There is enough evidence to support that cannabis acts on several segments of the bowel. It has been demonstrated that interaction through inhibition of intrinsic cholinergic mechanisms can result in cannabis-induced inhibition of gastrointestinal motility. Fernández-Atutxa et al. and Olga et al. presented a 3 patient case series and a case report respectively with clinical presentation similar to our patient. These patients were diagnosed with intussusception with no apparent organic cause but had a history of extensive marijuana use. Our case presentation is intended to pay attention to adverse effects of cannabis in light of increasing legalization and increasing therapeutic use of cannabis and its derivatives.
3234 Unique Case of Gastroenteritis Presenting as Pneumatosis Intestinalis With Emphysematous Gastritis and Portal Vein Gas: Do Not Take Gastroenteritis Lightly
Authors: Mehmood Asif , Ullah Waqas , Rashid Mamoon Ur , Essrani Rajesh 
Published: October 2019

INTRODUCTION:
Pneumatosis intestinalis (PI) refers to presence of multiple thin gas filled cysts in the wall of gastrointestinal tract. It is a uncommon entity and can involve any site from stomach to the rectum. Isolated stomach involvement is very rare. PI can represent a wide spectrum of diseases with variable prognosis.

CASE DESCRIPTION/METHODS:
An 87-year-old male presented with multiple episodes of non-bloody watery diarrhea associated with nausea and epigastric pain for 2 days. He has past medical history of hypertension, hyperlipidemia and coronary artery disease with bypass surgery. Denied any fever, vomiting, sick contact, recent travel or chest pain. On physical exam, blood pressure was 146/90 mmgh, pulse rate 90/min, respiratory rate 20/min with temperature of 100.5 F. The abdomen was diffusely tender with hypoactive bowel sounds without rebound tenderness or guarding. The laboratory findings showed normal blood counts except leukocytosis of 14000/ml, elevated urea levels of 30 mmol/L, creatinine levels of 1.4 mg/dl and potassium of 3.5. A CT abdomen/pelvis with contrast showed air in gastric wall and air in portal vein which was concerning for emphysematous gastroenteritis. Further work up came back negative including blood cultures, stool studies, clostridium difficile and lactic acid levels. He was admitted to ICU and evaluated by surgeon, Gastroenterology and Infectious disease specialist. Patient was made nothing per oral, received intravenous fluids and IV antibiotics including Ciprofloxacin and Metronidazole. With no other exact cause of PI, the patient's presentation was ultimately thought to represent a mild bacterial infection yielding minimal clues to the definitive diagnosis aside from radiographic data. The patient actually did very well with conservative management and was discharged on antibiotics after a few days with plan to follow up with an outpatient CT scan.

DISCUSSION:
Emphysematous gastritis with air in portal vein is very rare with underlying gastroenteritis, a worldwide very common disease. It can be easy to miss especially if presentation is benign. This is extremely rare and can easily mimic viral gastroenteritis. High index of suspicion with low threshold of scan can be lifesaving.