Supplement Gone Wrong: Drug-Induced Liver Injury Caused by Artemisinin

Introduction: Drug-induced liver injury (DILI) is defined as hepatic dysfunction caused by prescription medications, supplements, or xenobiotics after alternative causes have been excluded. As one of the leading causes of acute liver failure, DILI should be considered when patients present with hepatic dysfunction. We present a case of symptomatic DILI secondary to artemisinin use. Case Description/Methods: A 78-year-old Chinese man with no medical history presented to the hepatology clinic with 10 weeks of jaundice, weakness, and pruritis. He started taking Artemisinin/ Bioperine 12 weeks ago to prevent COVID-19 but stopped 3 weeks ago. He denied abdominal pain, a family history of liver disease, substance/alcohol use, and taking other concomitant drugs. Physical examination revealed scleral icterus and no other signs of chronic liver disease. Laboratory studies showed total bilirubin 11 mg/dL, alkaline phosphatase 293 U/L, aspartate transaminase 170 U/L, and alanine transaminase 196 U/L with negative workup for hepatitis A, B, and C. CT abdomen and MRCP were unremarkable for liver or biliary pathology. Further serological workup was negative and follow-up labs revealed normalization of liver enzymes and bilirubin. Given the patient's improvement, liver biopsy was not pursued. The patient was instructed to avoid supplements unless prescribed by a physician. Discussion(s): DILI is a global issue with an estimated annual incidence rate of 13.9 to 24.0 per 100,000 persons. Diagnosing DILI is important as it can cause acute liver injury and liver failure in certain cases. Since COVID-19 emerged, supplement use has increased given claims of boosting the immune system. Artemisinin is an herb used in traditional Chinese medicine with antimalarial activity investigated to be a possible COVID-19 treatment, but no current evidence exists to support it being effective against COVID-193. Our patient's supplement also contained Bioperine, a black pepper extract, which is likely benign. Contrarily, artemisinin is a well-described cause of idiosyncratic acute liver injury and hepatotoxicity, causing self-limited mild to moderate transaminitis but also severe cases requiring emergent livertransplantation. Our patient's unrevealing workup, his spontaneous improvement correlating with supplement discontinuation, and RUCAM score of 7 led to high suspicion of DILI secondary to artemisinin. Providers should always ask patients about supplement use and consider DILI when patients present with liver injury. (Table Presented).

Cool Your Jets Bro

History: Twenty-two year old male basic trainee was brought to the ED after collapsing during a routine ruck march. At mile 8/12, soldier was noted to develop an unsteady gate and had witnessed loss of consciousness. A rectal core temperature was obtained and noted to be >107degreeF. Cooling initiated with ice sheets and EMS was activated. On arrival to the ED, patient demonstrated confusion and persistently elevated core temperatures despite ice sheeting, chilled saline and cold water bladder lavage. Cooling measures were discontinued after patient achieved euthermia in the ED;however, his temperatures subsequently spiked>103degreeF. Given rebound hyperthermia, an endovascular cooling (EVC) device was placed in the right femoral vein and patient was transferred to the ICU. Multiple attempts to place EVC device on standby were unsuccessful with subsequent rebound hyperthermia. Prolonged cooling was required. Physical Exam: VS: HR 121, BP 85/68, RR 22 SpO2 100% RA, Temp 102.4degreeF Gen: young adult male, NAD, shivering, A&Ox2 (person and place only) HEENT: Scleral anicteric, conjunctiva non-injected, moist mucus membranes Neck: Supple, no LAD Chest: CTAB, no wheezes/rales/rhonchi CV: tachycardia, regular rhythm, normal S1, S2 without murmurs, rubs, gallops ABD: NABS, soft/non-distended, no guarding or rebound EXT: No LE edema, tenderness SKIN: blisters with broad erythematous bases on bilateral heels Neuro: CN II-XII grossly intact, 5/5 strength in all extremities. Differential Diagnosis: 216. Septic Shock 217. Hypothalamic Stroke 218. Exertional Heat Stroke (EHS) 219. Neuroleptic Malignant Syndrome 220. Thyroid Storm Test Results: CBC: 18.2>14.5/40.6<167 CMP: 128/3.5 88/1831/2.7<104, AST 264, ALT 80, Ca 8.8 Lactate: 7.1 CK: 11 460 Myoglobin: 18 017 TSH: 3.16 CXR: No acute cardiopulmonary process Blood Cx: negative x2 CSF Cx: Negative COVID/Influenza/EBV: Negative Brain MRI: wnl. Final Diagnosis: Exertional Heat Stroke. Discussion(s): No EVC protocols exist for the management of EHS or rebound/refractory hyperthermia. As a result, the protocol used for this patient was adapted from post-cardiac arrest cooling protocols. It is unclear if this adapted protocol contributed to his delayed cooling and rebound hyperthermia as it was not intended for this patient demographic/ pathophysiology. Furthermore, despite initiating empiric antibiotics upon admission, delayed recognition and tailored therapy for his bilateral ankle cellulitis may have contributed to the difficulty in achieving euthermia. In summary, more research needs to be done to evaluate and develop an EVC protocol for EHS. Outcome(s): Euthermia was achieved and maintained after 36 hours of continuous EVC, at which point it was discontinued. His CK, AST/ALT, creatinine and sodium down-trended after discontinuation of EVC. Patient's antibiotics were transitioned to an oral formulation for treatment of ankle cellulitis and he was prepared for discharge. He was discharged with regular follow-up with the Fort Benning Heat Clinic. Follow-Up: After discharge, patient had regularly scheduled visits with the Fort Benning Heat Clinic. His typical lab markers for exertional heat stroke were regularly monitored. He had continued resolution of his Rhabdomyolysis, acute kidney injury and hyponatremia with typical treatment. Soldier returned to duty after 10 weeks of close monitoring and rehabilitation.

Bupivacaine-Induced Hepatotoxicity in a Healthy Patient Without Chronic Liver Disease After Shoulder Arthroscopy

Introduction: Bupivacaine is a local anesthetic which has been increasingly used in the post-operative state for pain control. Hepatotoxicity is a rare complication, and few cases are reported in patients with chronic liver disease. We present a case of acute liver injury from bupivacaine use in a healthy patient without prior history of liver disease. Case Description/Methods: A 68-year-old female with a past medical history of primary hypertension and recent nontraumatic complete tear of the right rotator cuff, presents to the hospital with fatigue, loss of appetite, and nausea. She recently underwent an arthroscopy of the right shoulder with repair of the rotator cuff two weeks prior. Her surgery was uncomplicated, and patient was started on bupivacaine ONQ pump infusion at 5 ml/hr for three days for post-operative pain. Further history reveals patient is non-alcoholic without prior liver disease, including cirrhosis. Review of systems is concerning for associated generalized abdominal discomfort. Physical exam demonstrated jaundice with scleral icterus with mild periumbilical tenderness to palpation without hepatosplenomegaly or ascites. Labs demonstrated elevated total bilirubin of 10.2 mg/dL with Alkaline phosphatase, ALT, and AST being 924 U/L, 429 U/L, and 279 U/L, respectively. Imaging studies including CT abdomen and pelvis with contrast, abdominal ultrasound, MRCP, and portal vein doppler were negative. Additional work up for underlying liver disease including acetaminophen and ethanol levels, SARS-CoV2, Hepatitis panel, EBV antigen, and urine toxicology were negative. It was determined patient had bupivacaine induced hepatotoxicity. Patient's health improved with conservative management and she was discharged with instructions for close monitoring of her LFTs. Discussion(s): Bupivacaine is an amino-amide anesthetic which binds to the intracellular portion of voltage-gated sodium channels and prevents depolarization of pain signals. It is metabolized by the liver and thus reports of hepatotoxicity, although rare, occur in patients with underlying liver pathology. Our patient became symptomatic with acute rise in LFTs. An extensive workup for other etiologies of acute liver toxicity was negative. Rapid vascular uptake of the drug is the most common reason for bupivacaine toxicity;and this remains a possibility for the mechanism of toxicity in our patient. A prior case report of bupivacaine hepatotoxicity demonstrated a cholestatic pattern, which is consistent with our findings.

Hepatotoxicity From Marijuana Gummies

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).

A Case Report of Ivermectin-Induced Liver Failure

Introduction: Ivermectin is an antiparasitic medication that is primarily metabolized by the liver. During the COVID-19 pandemic, researchers demonstrated that Ivermectin successfully inhibited the replication of SARS-COV-2 in vivo, but current research has failed to demonstrate clinical benefit for treatment of COVID-19. Despite this, misinformation campaigns have misled patients to ingest Ivermectin at concentrations meant for domestic animals. Here, we present a case of acute liver failure secondary to the use of Ivermectin. Case Description/Methods: A 61-year-old man with medical history of ischemic cardiomyopathy with last echocardiogram showing ejection fraction at 21%, atrial fibrillation on warfarin for oral anticoagulation, and previously treated Hepatitis C presented with generalized weakness and yellowish discoloration of the skin worsening over the last two weeks. The patient denied significant alcohol use, acetaminophen use, or illicit drugs. He admitted to injecting himself with two doses of weight-based horse ivermectin, for COVID prophylaxis, two weeks prior to his presentation. Physical exam was pertinent for scleral icterus and hepatomegaly with no abdominal tenderness. Initial labs revealed elevated liver chemistries in a mixed pattern (Figure 1). Acute hepatitis panel, HSV, and CMV were negative. Hepatitis C antibodies were positive, but the patient was in sustained virologic response. Full workup for chronic liver disease was unremarkable. Ultrasound revealed hepatosplenomegaly with patent portal and hepatic vasculature. Subsequently, the patient developed hepatic encephalopathy along with his coagulopathy, raising concern for acute hepatic failure. The patient was transferred to the ICU and started on NAcetylcysteine, rifaximin, and supportive care. The patient recovered well and fortunately did not require liver transplant. Discussion(s): While the FDA recommends against the use of Ivermectin for COVID-19, many continue to inappropriately consume it. Ivermectin-induced liver failure is a rare but deadly side effect. Given our patient's rapid onset of symptoms post-self injection of Ivermectin, his liver injury was presumed to be related to Ivermectin. The drug interaction between Ivermectin and warfarin had worsened the patients coagulopathy. Physicians should be aware of the ways Ivermectin overdose may clinically present to avoid delayed treatment. This case demonstrates the detriments of perpetuation of medical misinformation to care.

Complete response to eculizumab in atypical hemolytic uremic syndrome with homozygous C3 mutation

Case Report: Atypical Hemolytic Uremic Syndrome (atypical HUS) is a rare and severe form of thrombotic microangiopathy (TMA) characterized by thrombocytopenia, intravascular hemolysis, and acute kidney injury with an incidence of 1 per million.1 Dysregulation and overactivation of the complement alternative pathway due to genetic mutations have been detected in 40-60% of patients with sporadic or familial atypical HUS.2,4 Triggers include viral illness, pregnancy, malignancy, sepsis, or sporadically with no known inciting event.1 Atypical HUS is a severe disease with a 2-10% risk of mortality, 33% risk of end-stage renal failure, and 50% chance of relapse.5 A 24-year-old female with prior history of atypical HUS at the age of 16 (with response to plasmapheresis) presented to the ER with a 5-day history of fever, chills, sore throat, nausea, vomiting, and dark urine. She tested positive for COVID-19. The exam revealed scleral icterus and scattered petechiae. Labs demonstrated nadir hemoglobin (Hgb) of 9.2 g/dL, platelet count of 52 000k/uL, haptoglobin < 30 mg/dL, peak LDH 1128U/L and creatinine 4.62 mg/dL. Urinalysis is consistent with hemoglobinuria. Schistocytes were noted on the peripheral smear. Rapid streptococcal antigen test and C3, C4, and IgA levels were unremarkable. Chest X-Ray, X-ray KUB, and ultrasound abdomen were unremarkable. The pregnancy test was negative. ADAMTS13 was >100%. Genetic analysis after the initial episode at age 16 revealed autosomal recessive inheritance c.193A > c gene mutations in C3. The patient received IV fluids, ceftriaxone for cystitis, and two units of Fresh Frozen Plasma. She initiated treatment with eculizumab. She also received the MENVEO and meningitis B vaccine per protocol due to the risk of meningitis from terminal complement deficiencies. After 4 infusions of eculizumab, patient's labs improved to platelet count of 307 000 k/uL, Hgb 12.2 g/ dL (nadir 9.2 g/dL), haptoglobin 78 mg/dL normalization of LDH and improved creatinine. Atypical HUS is a rare form of TMAwith mutations in C3 noted in 5% of cases. Complement cascade dysfunction leads to endothelial deposits and microvasculature damage. The resulting prothrombotic state causes obstructive microvascular thrombi predominantly affecting the kidneys but can cause multiorgan dysfunction. The SARS-CoV-2 virus may precipitate atypical HUS relapse due to endothelial damage and complement activation further intensified in patients with existing complement aberrations. Plasma exchange remains a standard of care for atypical HUS, as it effectively removes the antibodies and other proteins. Eculizumab a humanized monoclonal IgG antibody binds to complement proteins, preventing cleavage into C5a and C5b blocking C5b-9(MAC) activation. In patients with CFH, CFI, C3, and CFB mutations, eculizumab is the preferred intervention. Copyright © 2023 Southern Society for Clinical Investigation.

Severe progression of autoimmune hepatitis in a young COVID-19 adult patient: A case report

Rationale: The impact of COVID-19 in patients with autoimmune liver disease treated with immunosuppressive therapy has not been described so far. This case report describes the clinical course of a patient with autoimmune hepatitis (AIH) who developed COVID-19 and the features of cytokine syndrome leading to its deterioration in our intensive care unit. Patient's Concern: A 28-year-old male presented with generalized anasarca for two weeks and chronic liver disease for 8 months. Diagnosis: AIH and Covid-19 with features of cytokine storm syndrome. Interventions: Intravenous furosemide, mannitol, syrup lactulose, steroids (prednisolone 40 mg), azathioprine 1 mg/kg body weight, rifaximin, vitamin K, and blood products. Outcomes: The patient had hepatic encephalopathy and AIH and died on the 10th day after admission despite ventilatory support, sustained low-efficiency hemodialysis, and resuscition. Lessons: The dramatic release of cytokines and the inflammatory-immune responses not only alter the pathophysiology but also affects the onset and severity of disease progression in patients with AIH.

HEMOLYTIC ANEMIA EXACERBATION IN CHRONIC PAROXYSMAL NOCTURNAL HEMOGLOBINURIA AFTER COVID-19 VACCINATION

SESSION TITLE: Issues After COVID-19 Vaccination Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematologic disorder that can lead to thrombosis, hemolytic anemia and leukemia. Though there are documented relationships between autoimmune hemolytic anemia (AIHA) and COVID-19 infection, this is the first to highlight aa potential association between PNH exacerbations and COVID vaccinations. CASE PRESENTATION: A 38 year-old female with a history of chronic paroxysmal nocturnal hemoglobinuria (PNH) currently on maintenance ravculizumab therapy presented with 3 days of generalized fatigue, chills, and worsening scleral icterus. She reports being unable to move out of the bed with concomitant somnolence. Of note, she received her second dose of the Moderna COVID-19 vaccine 2 days prior to symptom onset and not had any similar symptoms prior to this episode. Patient was hemodynamically stable on admission and afebrile. Physical exam revealed generalized lethargy/weakness and jaundice. Chest x-ray did not demonstrate any evidence of infection or pleural effusions. Initial complete blood count showed a hemoglobin of 5.9 g/dL, compared to her baseline of 9 without any evidence of bleeding. Absolute reticulocyte and bilirubin levels were elevated to 295.2 x 109 and 4.7 mg/dL respectively with a haptoglobin of <20 mg/dL. She received a total of 3 units of packed red-blood cells with subsequent stable hemoglobin levels and did not require emergent use of glucocorticoids or plasma exchange. Her lethargy improved slowly, and within a week, she returned back to her baseline functional status. She was ultimately stable and discharged for follow up with her hematologist without any complications. DISCUSSION: Though the sequelae of COVID-19 infections and associated hematologic diseases have been extensively established, the pathogenesis of COVID-19 vaccinations associated exacerbations remain unclear. Given the timing of the onset of our patient's symptoms, it is highly suggestive that her second COVID-19 vaccination was the inciting factor for her acute hemolytic anemia. It is crucial to be cognizant of the potential hematologic side effects in individuals with rare auto-immune disorders such as PNH and take into consideration the timing of vaccination or booster administrations. CONCLUSIONS: While COVID-19 vaccination benefit most likely outweighs the risks for this specific patient population, our case raises the question about the need for extra precautions in patients with known PNH associated AIHA including the timing of PNH treatment before receiving the vaccination. Reference #1: Algassim AA, Elghazaly AA, Alnahdi AS, Mohammed-Rahim OM, Alanazi AG, Aldhuwayhi NA, Alanazi MM, Almutairi MF, Aldeailej IM, Kamli NA, Aljurf MD. Prognostic significance of hemoglobin level and autoimmune hemolytic anemia in SARS-CoV-2 infection. Annals of Hematology. 2021 Jan;100(1):37-43. DISCLOSURES: No relevant relationships by Suhwoo Bae No relevant relationships by Edward Bae No relevant relationships by Joseph You

Tissue-specific evidence for SARS-CoV-2 within intraocular tissues

Purpose : To systematically investigate ocular changes in autopsied eyes from fatal cases of Coronavirus disease 2019 (COVID-19) and to investigate the localization of severe acute respiratory syndrome coronavirus (SARS-CoV-2) within ocular structures. Methods : Macroscopic and microscopic histopathological evaluation was performed and the localization of SARS-CoV-2 RNA within ocular tissues investigated using an in situ hybridization (ISH) technique in 13 eyes. Contralateral eyes were freshly dissected, and droplet digital polymerase chain reaction (ddPCR) assay was performed on ocular fluids and tissues to quantify SARS-CoV-2 RNA. Results : A total of 21 fatal COVID-19 cases were included (mean age, 60.2 years [range, 27- 91 years];23.8% female). Histopathological abnormalities include vascular changes (61.9%), cytoid bodies (52.4%), and retinal edema (23.8%) with minimal inflammation (0.09%) were observed. Non-CMV viral inclusions were identified in one eye. No CMV positivity was detected. Of the 21 contralateral eyes tested by ddPCR, 14 tested positive for SARS-CoV-2. Using ddPCR and ISH, SARS-CoV-2 localization was observed in the following ocular tissues and fluid: cornea (27.3%), aqueous (26.3%), lens (54.5%), vitreous (15.0%), retina (22.2%), choroid/sclera (47.4%), and optic nerve (50.0%). The choroid/sclera, optic nerve and lens were the most frequent ocular structures found to be ddPCR positive. Evidence of replication was detected in four cases. Conclusions : Our results suggest that SARS-CoV-2 localizes to intraocular tissues. However, histological changes observed are likely a secondary hemodynamic change rather than primary effect of the virus.

LEPTOSPIROSIS IN THE CITY: A CASE REPORT

CASE: A 58 year-old undomiciled man with no medical history presented with three days of anorexia, malaise, abdominal pain, and decreased urination. Exam was notable for scleral icterus. Lab-work revealed sodium 133 mEq/L, BUN 132mg/dL, creatinine 8.82 mg/dL, platelet 64 K/uL, total bilirubin 6.4 mg/dL, direct bilirubin 5 mg/dL. Lab-work two years prior was normal. HCV antibody was reactive, urinalysis revealed microscopic hematuria, and cocaine was detected on toxicology. Abdominopelvic CT, MRCP and renal sonogram were non-pathologic. On hospital day 5 his creatinine downtrended but total bilirubin continued to rise to a peak of 11.2 mg/dL and a leukocytosis without fever developed (peak 21.2 K/uL). Ceftriaxone was started empirically and a workup of blood cultures, viral serologies, ANA, alpha-1 antitrypsin, complement, cryoglobulin, ceruloplasmin level, microsomal, smooth muscle and antimitochondrial antibodies was normal. Review of his history suggested exposure to rodents as he slept close to a dumpster. Pending Leptospirosis serology, the antibiotics were adjusted to doxycycline. At discharge, the WBC and platelet counts normalized while the bilirubin and creatinine downtrended. IgM serology for leptospira later resulted positive. IMPACT/DISCUSSION: Leptospirosis is a worldwide zoonotic disease commonly associated with moist environments, poor housing and inadequate sanitation. Rodents are important reservoirs, shedding spirochetes through urine. Human infection results from exposure to animal urine, contaminated soil or water, or infected animal tissue. Portals of entry include cuts, mucous membranes or conjunctivae. Person-toperson transmission is rare. The incubation period is 5-14 days and illness severity ranges from subclinical to life-threatening. Disease manifestations include jaundice with acute kidney failure (Weil's disease), rash, conjunctival suffusion, hyponatremia, thrombocytopenia, microscopic hematuria, myocarditis, pulmonary hemorrhage, and meningitis. A biphasic illness, the acute febrile bacteremic phase can last 2-9 days followed by a period of apparent improvement. An “immune” phase then follows characterized by development of complications, as in our patient. During this phase, leptospires are absent from blood but may appear in the urine. While human cases of leptospirosis are rarely reported in the US outside of Puerto Rico and Hawaii (in the absence of travel), there was a significant rise reported to the NYC DOH in 2021. A potential explanation is an increase in housing insecurity and disruptions to waste management as a consequence of the COVID-19 pandemic. CONCLUSION: Leptospirosis is an important consideration in at-risk populations who may unknowingly be exposed due to living conditions. Our case of unexpected Weil's disease in an urban setting underscores the importance of a thorough social history as well as timely recognition of uncommon infections as possible reversible causes of multi- organ failure in the context of a changing world climate.

ACUTE HEPATITIS AND RASH LINKED THROUGH EPSTEIN-BARR VIRUS

Epstein-Barr virus (EBV) hepatitis is well established, and most cases involves asymptomatic liver enzyme abnormalities. Albeit rare, viruses such as EBV have been reported to induce generalized pustular psoriasis (GPP);and exanthems such as GPP have been associated with acute hepatitis. This case describes a unique case of cholestatic hepatitis due to EBV, followed by a diffuse pustular rash suggestive of GPP. After complete resolution of the cholestatic hepatitis, the patient returned over a year later with concurrent hepatitis and diffuse pustular rash. Case: An obese 26 year-old African-American female presented to the hospital on three separate occasions over a 15 month span with slightly varying symptoms. At the index hospitalization she presented with fatigue and jaundice. Liver chemistries revlead a mixed pattern liver injury, see Table 1. Extensive serological evaluation was unremarkable, though antinuclear antibody and anti-smooth muscle antibody were mildly and non-specifically elevated, but IgG was normal. A liver biopsy was performed revealing portal and lobular inflammation with predominantly lymphocytic moderate micro-vesicular steatosis (Figure 1). EBV PCR returned positive at 20,737 IU/mL yielding a diagnoses of EBV-induced hepatitis. She returned to the hospital one week later due to a diffuse pruritic and painful rash. She had scleral icterus and diffuse erythematous plaques with tiny pustules dispersed over the body sparing the palms, soles, and mucosal surfaces. Laboratory values were overall improved as noted in Table 1. Punch biopsy of the right arm was suggestive of EBV induced GPP. She rapidly stabilized and was discharged the following day with triamcinolone 0.1% ointment. The patient had an uneventful convalescence and liver chemistries returned to normal. Approximately 15 months after her initial hospitalization, she presented with both recurrent hepatitis and a pustular, pruritic, erythematous rash with perioral and periorbital swelling. She denied taking any new medications or supplements. Labs revealed recurrent, though now primarily cholestatic liver injury, see Table 1. Results of a repeat thorough serological evaluation were negative, including for EBV-PCR and COVID-19. Abdominal ultrasound revealed a 16 cm hepatic length. Pustules, spongiosis, and edema were found on repeat skin biopsy, suggestive of GPP. She recovered quickly with systemic steroids. Awareness of GPP induced hepatitis can guide a judicious assessment of abnormal liver chemistries. Furthermore, unnecessary healthcare utilization can be avoided by providing appropriate and timely pharmacotherapy (i.e., corticosteroid taper) for on demand flares. (Figure Presented) (Table Presented) (Figure Presented)

Fluorescence in the Sclera, Nails, and Teeth Secondary to Favipiravir Use for COVID-19 Infections

Favipiravir, an antiviral agent originally used for influenza infections, has become popular due to its beneficial signals in coronavirus disease. It is currently used in some countries within COVID-19 treatment protocols. This is an initial report of favipiravir-related fluorescence observed in three healthcare providers working in the same ward in our hospital. All three individuals had been diagnosed with COVID-19 two months earlier and were treated with favipiravir. None of the three individuals received hydroxychloroquine or tetracyclines. Wood’s light examination led to an incidental discovery of favipiravir-induced fluorescence involving the sclera, nails, and teeth. In all patients, white linear, square, and band-like specks of fluorescence were noticed on the sclera of both eyes, some teeth, and the proximal part of all fingernails and toenails. Exposure of the eyes to the Wood’s light was for a brief duration of 3 to 5 seconds during examination and photodocumentation. Favipiravir might cause bright white fluorescence of nails, sclera, and teeth, detectable by Wood’s light even two months after its cessation.

Severe hypertransaminasemia in a pregnant woman with SARS-CoV-2 infection

Description of the case: A 38-year-old patient of Moroccan ethnicity, who had vaginally delivered a healthy baby girl in the obstetric ward the previous night, was transferred to the CoViD Hub of Varese Hospital due to the onset of nausea and emesis and severe hypertransaminasemia. The patient was known to be positive for SARS-CoV-2 infection but was not taking any medications at home. Physical examination was normal, except for scleral icterus. Laboratory tests were significant for bilirubin 2.52 mg/dl, AST 2729 U/L, ALT 513 U/L, LDH>1800 U/L;we also found mild thrombocytopenia (104,000/L), INR 1.24, d-dimer>9000 ng/ml, prolonged prothrombin time, and reduced fibrinogen levels. Serological tests were negative for hepatitis A, B, C, and E, EBV, CMV, HSV type 1 and 2, and HIV. Autoimmune or toxic hepatitis was excluded. No teardrop-shaped erythrocytes were visualized. No vaginal bleeding was found. HRCT showed diffuse multiple bilateral consolidations, and abdomen CT excluded portal thrombosis. Infusive fluid and prophylactic therapy with sodium enoxaparin were started. During hospitalization, the detection of SARS-CoV-2 RNA in the nasopharynx sample was persistently positive. On the tenth day post-hospitalization, the patient was discharged with normalization of liver values and clinical well-being. Conclusions: Severe acute hepatitis has been reported in patients with severe CoViD-19, but it is rare in pregnant women with asymptomatic SARS-CoV-2 infection without other pregnancy-related disorders, as in the present case.

Case series of scleral patch grafts during COVID-19 pandemic.

Scleral graft is done for clinical conditions as scleral melt post pterygium surgery, immune or infection related scleral melt, for covering the tubes of Ahmed glaucoma valve implant, for covering the orbital implants post enucleation, etc. A review of literature revealed the use of sclera for corneal perforations in the past, but became obsolete after the cornea being used for patch grafts. Now in this COVID-19 time, due to scarcity of corneal tissue, this technique of scleral patch grafts can be considered as an alternative to corneal patch grafts, which serves well the tectonic/therapeutic purpose and helps salvage the eye.

A novel approach to anterior segment imaging with smartphones in the COVID-19 era.

PURPOSE: To report a novel, telemedicine-friendly, smartphone-based, wireless anterior segment device with instant photo-documentation ability in the COVID-19 era. METHODS: Anterior Imaging Module (AIM) was constructed based on a 50/50 beam splitter design, to match the magnification drum optics of slit-lamps with a three-step or higher level of magnification. The design fills the smartphone sensor fully at the lowest magnification and matches the fixed focus of the slit-lamp. It comes with a smartphone for instant photo-documentation, an in-built software application for data-management and secure HIPAA compliant cloud storage, and a Bluetooth trigger for a one-tap image capture. The construction of the device is explained, and the optical resolution measured using U.S. air-force resolution test. AIM's performance was characterized with traceability to internationally relevant performance standards for digital slit-lamps after image quality assessment through a pilot study. RESULTS: Clinically useful anterior segment images were obtained with both diffuse and slit illumination at different magnification settings with the highest magnification (40X) resolution of 359 lines per cm and the lowest magnification (16X) resolution of 113 lines per cm. CONCLUSION: AIM is a novel, wireless, telemedicine-enabled design that digitizes existing, analog slit lamps with at least three-step magnification. The settings ensure the focus is determined purely by the position of the slit-lamp. Hence, the image viewed and captured on the smartphone is exactly what the clinician sees through the eyepiece. This helps in maintaining distance from the patient in the ongoing COVID-19 pandemic, as well.