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Introduction: We report a case of drug-induced liver injury (DILI) induced by cannabis gummies containing Corydalis Rhizome. Case Description/Methods: A 37-year-old female presented to her primary care clinic with recurrent fevers, night sweats, and myalgias for 7 weeks accompanied by eye redness, brain fog, headache, nausea, and abdominal pain. She denied rashes, tick-bites, cough, dyspnea, chest pain, joint swelling, or genitourinary symptoms. Past medical history was notable for IBS, migraines, and anxiety. She reported edible marijuana use four times a week, rare alcohol use, and denied tobacco use. She denied a family history of liver disease. Physical exam was notable for tachycardia to 110 and scleral injection with the remainder of vitals and exam unremarkable. Initial labs were notable for AST 61, ALT 44 and CRP of 12. CBC, BMP, urinalysis, ESR, blood cultures, blood smear for parasite screen, tests for Lyme disease, Babesia, Tularemia, Anaplasma, Ehrlichia, Rickettsia, EBV, HIV, RPR, ANA, CMV, parvovirus B19, and chest x-ray were all negative. The patient was referred to infectious disease with further testing for West Nile, Leptospira, lymphocytic choriomeningitis virus, and COVID-19 returning negative. Repeat LFTs showed worsening transaminitis with ALT 979 and AST 712, alkaline phosphatase 88, total bilirubin 0.7, and albumin 4.9. Hepatitis workup including hepatitis A, B, and C, HSV, EBV, VZV serologies, AMA, ASMA, antiLKM Ab, acetaminophen level, INR, iron panel, CPK, TSH, and abdominal ultrasound were all normal. It was later discovered that her marijuana gummies contained Corydalis rhizome extract known to be hepatotoxic. Cessation of this drug was strongly advised. She was discharged with hepatology follow-up and underwent a liver biopsy showing patchy periportal and lobular inflammation with extension across the limiting plate, hepatocyte injury and apoptosis, and increased lipofuscin for age compatible with mild to moderate hepatitis. She had complete recovery after cessation of Corydalis-containing gummies. (Figure) Discussion: Our patient consumed '1906 Midnight', an American cannabis brand containing Corydalis rhizopus 100 mg, advertised to improve sleep, pain, and have a liver protective effect. A Korean systematic review on herbal-induced liver injury reported that Corydalis was the 3rd most frequent causative herb, with 36 cases. Although there are several personal accounts on social networking sites and other websites, there are no American-based publications reported on DILI from Corydalis. (Table Presented).
ABSTRACT
Introduction: Gestational alloimmune liver disease (GALD) is a leading cause of neonatal acute liver failure (NALF), a rare but important diagnosis. Congenital portosystemic shunts (CPSs) are rare vascular anomalies that leave patients at risk for developing a wide spectrum of complications and have not been previously associated with GALD. In this case, we present a newborn male with NALF secondary to GALD complicated by intrahepatic shunts. Case Description: The patient is a 30 weeks gestational age male born to a 28-year-old gravida 2 para 0 mother via urgent cesarean section for severe placental malperfusion. The pregnancy was complicated by severe intrauterine growth restriction, oligohydramnios, and maternal COVID-19 infection. The patient's initial NICU course was remarkable for respiratory distress requiring ventilatory support, hypotension requiring inotropes and stress dose steroids, and coagulopathy with bleeding requiring transfusion of multiple blood products. An abdominal ultrasound showed large congenital intrahepatic portosystemic shunts. Over the course of the hospitalization, the infant progressed to fulminant hepatic failure with associated coagulopathy, hypoalbuminemia, direct hyperbilirubinemia, and hyperammonemia. There was persistent anasarca in addition to elevated ferritin (1,922 ng/dL) and alpha-fetoprotein (97,855 ng/mL). Serial SARS-CoV-2 NAAT were negative. In consultation with the hepatologist there was high clinical suspicion for GALD, and treatment with intravenous immunoglobulin was initiated, however, no clinical or laboratory improvement was noted. Abdominal MRI showed progression of the large CPSs and enlargement of the hepatic arteries. The infant continued to deteriorate, was transitioned to comfort care, and died on day of life 82. A limited autopsy revealed a markedly edematous and jaundiced male with grossly enlarged liver with hepatocellular cholestasis, portal fibrosis, diffuse hepatobiliary iron depositions, and C5b9 positivity within hepatocytes confirming a diagnosis of GALD. Discussion: Neonatal hemochromatosis is the phenotypic result of severe liver injury leading to iron overload and extrahepatic siderosis, the mechanism of hepatic injury now recognized in GALD. Liver failure in newborns with GALD often presents with marked coagulopathy, hypoalbuminemia, and edema with and without ascites. The establishment of the diagnosis is crucial given without treatment, the prognosis is very poor. There have been no case reports of neonates with acute liver failure from CPSs or CPSs occurring with GALD. We hypothesize that the presence of CPSs worsens the clinical course of GALD through an unknown mechanism that further expedites hepatocellular damage. Furthermore, the role of SARS-CoV-2 infection and transmission in the neonatal population is still unknown. Conclusion: Neonatal acute liver failure caused by GALD is a rare but potentially fatal diagnosis. CPSs associated with GALD have not been previously documented. This case demonstrates the interplay of these disease entities likely contributing towards a more severe course of NALF and highlights the importance of early identification for guiding management. (Figure Presented).
ABSTRACT
Background: Coronavirus disease 2019 (COVID-19) is a respiratory system trophic disease. Liver involvement is emerging from recent data. Studies describing liver function test (LFT) abnormalities are sparse from our population. Aims: We studied LFT abnormalities in different categories of COVID-19 and its significance in relation to primary outcomes of in-hospital mortality. Methods: It was a retrospective study from a single center of a metropolitan city. All consecutive patients with proven COVID19 by reverse transcriptase-polymerase chain reaction from 23rd March 2020 till 31stOctober 2020 were enrolled. Of 3280 case records profiled, 1474 cases were included in the study. Clinical characteristics, biochemical parameters and outcomes were recorded. Results: Deranged LFTs were present in 681/1474 (46%) patients. Hepatocellular type of injury was most common (93%). Patients with deranged LFTs had more probability of developing severe disease (P<0.001) and mortality (P<0.001). Higher mean age (P<0.001), male gender (P<0.001), diabetes mellitus (P<0.001), chronic kidney disease (P<0.02) cirrhosis (P<0.001), lower oxygen saturation (SpO2) levels at admission (P<0.001), higher serum creatinine (P value<0.001), D-dimer levels (P<0.001) and positive radiological findings on Chest X-ray (P<0.001) were associated with deranged LFTs. Acute liver injury was seen in 65 (4.33%) cases on admission and 57(3.5%) cases during hospital stay. On admission, raised serum bilirubin, aspartate and alanine transaminases, international normalized ratio and low serum albumin were found to be significant. However, on multivariate analysis for predicting mortality, age, serum creatinine, and PaO2/FiO2 ratio only were found to be significant (P<0.001). Conclusion: In COVID-19, LFT abnormalities are common and multifactorial. As severity of disease progresses, derangement in LFT’s increase. However, it is not associated with in- hospital mortality.
ABSTRACT
Background: Multisystem inflammatory syndrome in children (MIS-C) has been recognised as a rare and serious complication that involves multiple systems. Gastrointestinal (GI) symptoms like pain abdomen, vomiting, loose stools are common presenting features. Despite an abundance of ACE2 and TMPRSS2 cell receptors in intestine and biliary epithelium severe liver dysfunction is uncommon and very few studies have elaborated hepatic manifestations. Aims: To analyse spectrum of hepatic manifestations in MIS-C. Methods: We retrospectively reviewed the data of children diagnosed with MIS-C at our centre during first and second COVID wave (April 2020-May2021). 30 children were identified and recruited in the study. Their demographic, clinical and biochemical parameters were studied. Results: The mean age of presentation was 7 years. 76.6%(n=23) were male and 23.3%(n=7) were female. 90%(n=27) children had concomitant or isolated gastrointestinal complaints. 44.4% presented with abdominal pain (n=12), 33.3%(n=9) had loose stools, 18.5%(n=5) had vomiting. Only 1 child presented with blood in stool. All patients had positive COVID-19 IgG antibodies (mean titre- 40.1AU/ml). Mean C-reactive protein was 94.7mmHr. 50%(n=15) had deranged liver function tests. Both hyperbilirubinemia with raised liver enzymes were noted in 3(20%), both aspartate aminotransferase (AST) and alanine aminotransferase (ALT) elevation in 8 (53.3%), isolated AST elevation in 4 (26.6%). International normalised ratio (INR) was normal in all. Abdominal imaging (n=8) was normal in 2(25%), two showed distal ileal diffuse mural thickening, two had cholecystitis and one had pancreatitis. 1 expired (3.3%) and 29(96.6%) were discharged successfully. Conclusion: GI manifestations are common and so is the hepatobiliary involvement. Hepatocellular injury leading to hepatitis pattern is common, but involvement of pancreatico-biliary system should also be ruled out. Prognosis is excellent without any residual damage to the liver clinically, biochemically, and radiologically.