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Introduction: Disseminated histoplasmosis (DH) presents as primarily lung manifestations with extrapulmonary involvement in immunocompromised hosts. Granulomatous hepatitis as first presentation of DH in an immunocompetent host is uncommon. Case Description/Methods: 25-year-old female presented with one month of fever, fatigue, myalgias, 30-pound weight loss, cough, nausea, vomiting, and epigastric pain. She has lived in the Midwest and southwestern US. Presenting labs: TB 1.9 mg/dL, AP 161 U/L, AST 172 U/L, ALT 463 U/L. Workup was negative for COVID, viral/autoimmune hepatitis, sarcoidosis, tuberculosis, and HIV. CT scan showed suspected gallstones and 9 mm left lower lobe noncalcified nodule. EUS showed a normal common bile duct, gallbladder sludge and enlarged porta hepatis lymph nodes which underwent fine needle aspiration (FNA). She was diagnosed with biliary colic and underwent cholecystectomy, with white plaques noted on the liver surface (A). Liver biopsy/FNA showed necrotizing granulomas (B) and fungal yeast on GMS stain (C). Although histoplasmosis urine and blood antigens were negative, histoplasmosis complement fixation was >1:256. She could not tolerate itraconazole for DH, requiring amphotericin B. She then transitioned to voriconazole, discontinued after 5 weeks due to increasing AP. However, her symptoms resolved with normal transaminases. At one year follow up, she is asymptomatic with normal liver function tests. Discussion(s): DH is a systemic granulomatous disease caused by Histoplasma capsulatum endemic to Ohio, Mississippi River Valley, and southeastern US. DH more commonly affects immunocompromised hosts with AIDS, immunosuppressants, and organ transplant. Gastrointestinal involvement is common in DH (70-90%) with liver involvement in 90%. However, granulomatous hepatitis as primary manifestation of DH is rare (4% of liver biopsies). Hepatic granulomas are seen in < 20%. Patients may present with nonspecific systemic symptoms. Serum/urine antigens may be negative. Gold standard for diagnosis is identifying yeast on tissue stains. Recommended treatment is amphotericin B followed by 1 year of itraconazole. However, shorter treatment duration may be effective in immunocompetent hosts. This case is unique in that granulomatous hepatitis was the first presentation of DH in our immunocompetent patient diagnosed on EUS FNA and liver biopsy. Clinicians must have a high degree of suspicion for DH in patients with fever of unknown origin especially in endemic areas regardless of immunologic status. (Table Presented).
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The severe acute respiratory syndrome coronavirus-2 (SARS CoV-2) infection and associated (COVID-19) pandemic disrupted the healthcare systems of most countries because of the overwhelming demand for COVID-19 care and the ensuing diversion of resources and public attention to this purpose. The WHO goals for HBV and HCV elimination are thus facing major hurdles regarding both screening and treatment, and are at risk of failure. Because of the pandemic, hospital liver care departments have reallocated health professionals and reduced or suspended outpatient care. Hepatitis elimination programs and interventions (screening, diagnosis, and treatment) have been reduced or halted altogether. The Egyptian Liver Research Institute and Hospital (ELRIAH) reported a reduction during 2020 vs. 2019 of 57.0% for HCV consultations and 87.2% for new referrals. In addition, Requests for HCV RNA testing were greatly affected, with 60.7% reduction in HCV RNA test requests between 2019 and 2020 with a drop of 86.9% in the number of HCV RNA-positive patients detected. In terms of HCV treatment rates;86.2% fewer patients with HCV started on antiviral treatment during the pandemic period compared to the year before. Regarding HBV, the reduction between 2019 and 2020 was 43.7% for consultations and 7.3% for new referrals. As a consequence, the number of HBsAg-positive individuals observed in ELRIAH decreased by 8.7%. Also, the requests for HBV testing were found to be highly affected. Consequently, the number of patients with detectable HBV DNA dropped by 8.3% and HBV treatment rates also decreased. In conclusion, the COVID-19 pandemic has had a significant impact on every step of the viral hepatitis cascade of care. Furthermore, HCC surveillance programmes are mostly halted.
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Background: Pediatric acute liver failure is a rare and serious life-threatening situation, principally for the 30 to 50% of children in whom the etiology of their liver failure is unclear or indeterminate. Treating these patients is challenging, requiring constant assessment over time with regular evaluation for possible liver transplantation. Children with pediatric acute liver failure of undetermined etiology have lower spontaneous survival and higher rates of transplantation and death than other diagnostic groups. Emerging evidence suggests that a subgroup of patients with indeterminate pediatric acute liver failure have clinical, laboratory, and liver biopsy features of immune dysregulation with a dense infiltration of CD8 T cells. Method(s): In 2022, we received percutaneous liver biopsies from three children with acute hepatic dysfunction that showed an increased number of lymphocytes including CD8 T cells. For each case, routine H&E stains with levels, special stains and immunostains were performed. The first biopsy was from an 18-month-old male who presented with COVID infection, pancytopenia, elevated transaminases, and synthetic liver dysfunction (elevated INR). The second was from a 9-year-old female with a history of elevated liver enzymes with no clear cause. The third case was from a 2-year-old male with elevated liver enzymes, coagulopathy, and cholestasis. Result(s): The three cases showed similar histopathologic findings;an acute liver injury pattern with lobular architectural disarray, giant cell formation, reactive changes, single cell necrosis, cholestasis and marked mixed lymphocytic infiltrates. The infiltrates were predominantly composed of CD8-positive T-lymphocytes with scattered neutrophils, eosinophils and rare plasma cells. Portal areas were mildly expanded with mild bile ductular proliferation and mild to moderate lymphocytic infiltrates. Immunostains for CD8 demonstrated that the infiltrates were predominantly composed of CD8-positive T-lymphocytes. All three patients received steroids and responded to treatment evidenced by normalization of liver enzymes and function. Conclusion(s): Dense hepatic CD8 T-cell infiltration is a major finding inactivated CD8 T-cell hepatitis. However, the percentage distribution of lymphocyte subtypes in the setting of hepatitis is not well established, and CD8 T-cell infiltration has also been described in cases of drug-induced hypersensitivity reactions, viral hepatitis, hemophagocytic lymphohistiocytosis, and macrophage activation syndrome, as well as autoimmune hepatitis. Further investigation is needed to better understand the diagnostic criteria in this disease.
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The proceedings contain 115 papers. The topics discussed include: prevention and health promotion regarding sexual transmitted infections among university students in Germany;sexual risk behavior and condom use among Arab men tourists in Pattaya, Thailand;prevalence of individuals with risk for severe COVID-19 in whom ritonavir-containing therapies are contraindicated or may lead to interactions with concomitant medications;therapy adjustment using proviral DNA information among multi-class resistant HIV-1 infected and ART-experienced patients;are we on track to reach the WHO elimination goals for viral hepatitis among HIV+-individuals? updates on HBV prevalence and incidence, 1996-2019;telehealth or in-person HIV care? care continuity drove the decision process during the COVID-19 pandemic. results from a qualitative study in South Carolina;high burden of human papilloma virus infection in people living with HIV;and safety and effectiveness outcomes from the CARISEL study: Phase 3b hybrid-3 implementation study integrating CAB+RPV LA Into European clinical settings.
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Case report Introduction: Toxic epidermal necrolysis (TEN), is an immune-mediated disease characterized by severe mucocutaneous symptoms and is the result of an inflammatory response that leads to keratinocyte necrosis and perivascular lymphocyte infiltration, mostly drug-related. Case report: A 35-year- old male, with a history of recently diagnosed systemic lupus under treatment with prednisone, hydroxychloroquine, mycophenolate and cotrimoxazole forte evolves with persistent proteinuria, it is decided to add losartan, chlorthalidone and atorvastatin. Nevertheless despite immunosuppression, proteinuria and skin involvement persisted, so mycophenolate was suspended and a bolus of cyclophosphamide 1 g was administered. Eight weeks after adjusting treatment, the patient went to the emergency department due to a confluent, pruritic, maculopapular rash with blistering lesions on the trunk, upper limbs, face, and oral mucosa, associated with fever over 38degreeC, that evolved during one week. On admission, the following was confirmed: confluent erythematous macular exanthem associated with multiple flaccid blisters on the chest, upper limbs and neck, Nikolsky's sign (+), keratoconjunctivitis and dryness on the lips. Admission tests included complete blood count with no leukocytosis or eosinophilia, ESR 29 mm/hr, C-RP 19.8 mg/L, no liver profile abnormalities, creatinine 0.8 mg/dl, and urine test with proteinuria 300 mg/dl. Negative infectious study for mycoplasma, herpes 6 virus, cytomegalovirus, Epstein barr virus, hepatitis A, B, C, E and SARS-COV2 virus. Due to severe mucosal skin involvement, TEN/SJS was suspected v/s (TEN)-like Lupus presentation, drugs used prior to admission (chlorthalidone, losartan, atorvastatin) were discontinued, and treatment was started with Hydrocortisone 100 mg every 8 hours IV, Immunoglobulin 2 g/kg daily IV for 4 days, plus skin and mucous membrane care. Patient had a favorable evolution, with resolution of skin and mucosal lesions and no signs of infection. Skin biopsy showed necrotic epidermis, necrotic basal keratinocytes, and sparse lymphocytic inflammatory infiltrate in the papillary dermis, consistent with erythema multiforme/toxic epidermal necrolysis. Conclusion(s): Extensive mucosal involvement is one of the cardinal signs of the presentation of SJS/ETN and given its severity, a high index of suspicion is important with the consequent suspension of suspected drugs and support management for a favorable evolution. In this case the suspected culprit drug was the combination of cyclophosphamide and chlorthalidone, due to reports of increased toxicity of cyclophosphamide in combination with diuretic drugs.
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Viral infections affecting the liver had a serious impact on humanity, as they have led to significant morbidity and mortality in patients with acute and chronic infections. The discovery of the viral agents of severe acute hepatitis in children triggered interest of the scientific community to establish the pathogenesis and diagnostic techniques to identify the affected population. But, WHO, together with scientists in various affected countries, are working to understand the cause of this infection that does not appear to belong to any of the known five types of hepatitis viruses: A, B, C, D and E. Many cases of severe acute hepatitis of unknown origin in children <10 years of age were reported by the International Health Regulations (IHR) was mainly by adenovirus infection, HAdV-41. Although most acute infections cause mild disease and even go undetected, some can lead to complications and turn fatal. With the rapid scientific and technological advances in the last centuries, controlling and even curing the infections became a possibility, with a large focus on preventive medicine through vaccination. The review article describes the epidemiology, pathogenesis, clinical presentation, diagnostic tools and current medication regimens for severe acute hepatitis of unknown origin in children.Copyright © 2022, Global Research Online. All rights reserved.
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Background/Aim. Plasma containing a high titer of anti-SARS-CoV-2 antibodies, donated from individuals who re-covered from COVID-19, has the potential to be used as initial therapy for patients who have been infected (passive immunization). It is a challenge to find suitable donors. The aim of the study was to successively monitor antibody titer in donations and to investigate the correlation between an-tibody titer and the severity of the clinical manifestations. Methods. The retrospective study was conducted from May 1 to October 31, 2020, at the Blood Transfusion Insti-tute of Vojvodina. Donors had to meet certain criteria for inclusion in the study: proven SARS-CoV-2 infection, de-tected SARS-CoV-2 antibodies in the serum/plasma, ful-fillment of general criteria for performing plasmapheresis, and adequate laboratory findings. Results. During the study, 651 apheresis plasma units were collected and divided into two equal doses. Plasma was donated by 311 COVID-19 convalescents, including 208 (66.9%) men and 103 (33.1%) women. There were 15 (4.8%) plasma donors with asymptomatic infection, 235 (75. 6%) with a mild form of illness, 45 (14.5%) with a moderate form of illness, 16 (5.1%) with a severe form of illness, and none with a critical form of illness. Anti-SARS-CoV-2 IgG antibodies were pre-sent in the plasma of donors for more than 6 months after the disease. Plasma donors with a more severe clinical mani-festation of COVID-19 had stable antibody levels for a longer period. However, the Pearson correlation of clinical severity and antibody titer did not confirm a statistically sig-nificant correlation between the variables. Conclusion. An-ti-SARS-CoV-2 antibodies were present in the sample of re-covered patients, plasma donors, for more than 6 months after the disease. Even though no statistically significant correlation was found between the anti-SARS-CoV-2 anti-body titer and the clinical severity of COVID-19, in patients with a more severe clinical manifestations of the disease, stable antibody levels were maintained for a longer period.Copyright © 2022 Inst. Sci. inf., Univ. Defence in Belgrade. All rights reserved.
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Aim: Transmission of SARS-CoV-2 infection can easily occur through direct or close contact with infected people, just as with other infectious diseases. Therefore, it is important to detect it prior to the intervention for protecting the health of both the healthcare worker and the patient. In the study, it was aimed to determine the seropositivity rates of acute respiratory syndrome coronavirus 2, hepatitis A, hepatitis B, hepatitis C virus and human immune deficiency virus infections among children who underwent gastrointestinal endoscopy. Material(s) and Method(s): The study was conducted at the Department of Pediatric Gastroenterology of the Karabuk University in Turkey from December 2020 to December of 2021. A total of 175 children were included in the study. The study was divided into three age groups as follows: 1-6 years old, 7-12 years old and 13-18 years old. All children were screened for acute respiratory syndrome coronavirus 2, hepatitis A, hepatitis B, hepatitis C virus and human immune deficiency virus infections. Result(s): The median age was 12.5 years (1-18). The seroprevalence of acute respiratory syndrome coronavirus 2, Anti-HAV IgM, Anti-HAV IgG, HBsAg, Anti-HBs, Anti-HCV, Anti-HIV and were detected 0.57%, 0.57%, 42.8%, 0%, 58.8%, 1.1% and 0 % respectively. The seroprevalence of Anti-HAV IgG was significantly higher in children aged 1-6 years than in the group aged 13-18 years (95.7 vs 25.2: chi2=48.1, p=0.001). Discussion(s): Although seroprevalence rates prior to endoscopy were low in this study, viral screening, except for hepatitis A infection, is essential for the safety of both patients and healthcare.Copyright © 2022, Derman Medical Publishing. All rights reserved.
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Case Report: As COVID-19 infections became more common, children began presenting with multisystem inflammatory syndrome (MIS-C). It can be difficult to distinguish rare presentations of common diseases from MIS-C, especially when there has been a close contact with COVID-19. Epstein-Barr virus (EBV) is a universally common infection with 90% of individuals showing serological signs of past infection. Both MIS-C and EBV can present with similar signs and symptoms. Our case aims to remind the reader to keep in mind uncommon presentations of common viral infections which may mimic MIS-C. Case Presentation: A previously healthy 5-year-old girl presented with persistent fevers for 12 days, associated with stomatitis, vomiting, and diarrhea. Physical exam was significant for a moderately ill-appearance, small (<1 cm) left posterior cervical lymphadenopathy, and soft palate and buccal oral ulcers. Initial labs (see Table) revealed leukocytosis with reactive lymphocytes and cholestatic hepatitis with mild coagulopathy. Although she had no respiratory symptoms, CT chest revealed left upper lobe pneumonia. Abdominal ultrasound showed diffuse hepatosplenomegaly, gallbladder wall thickening, and enlarged epigastric lymph nodes. Echocardiogram showed normal systolic function and coronary arteries without dilation. Extensive viral and bacterial nasal swab and serologic testing, including for SARS-CoV-2 antibodies, was negative. On Day 2, her Monospot was positive, along with EBV viral capsid antigen IgM and IgG with the absence of EBV nuclear antigen IgG. In addition, serum PCR was positive for EBV. Management and Outcome: Due to persistent fevers on Day 3 of broad-spectrum antibiotics, coupled with a close contact with active COVID infection, she was treated with the MIS-C protocol of intravenous immunoglobulin G (IVIG), prednisone, and aspirin. Within a day of IVIG, she improved clinically and fever resolved. By discharge on Day 8, her lab values had begun to normalize. Discussion(s): EBV is known to present in children with typical infective mononucleosis symptoms such as fever, sore throat, and lymphadenopathy. However, these can be lacking which makes the diagnosis challenging. Although hepatitis is a common sequalae of EBV, EBV induced pneumonitis and stomatitis are rare, especially in immunocompetent individuals. While our patient improved after treatment with IVIG, suggesting MIS-C, we still attribute her illness to EBV, as IVIG has been shown to provide antiviral and anti-inflammatory benefit in EBV infections. This case highlights the challenge of recognizing and overtreating rare presentations of common viral infections in the face of an emerging disease such as MIS-C. Significant Laboratory Values [Table presented] Copyright © 2023 Southern Society for Clinical Investigation.
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SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Hemophagocytic Lymphohistiocytosis (HLH) is a rare, life-threatening hyperinflammatory syndrome caused by severe, dysregulated hypercytokinemia. This can be associated with genetic defects or immunologic triggers such as infection, malignancy or autoimmune disorder. The clinical picture consists of multi-organ failure including fever, hepatosplenomegaly, cytopenia,hypertriglyceridemia, hemophagocytosis, high ferritin and IL-2 levels, neurological and liver dysfunction. We present a case of a patient with HLH in the setting of Herpes Simplex Virus (HSV) and SARS-CoV-2 co-infection. CASE PRESENTATION: A 39-year-old male presented to the ER with dyspnea and was found to have COVID-19 pneumonia. He had worsening hypoxemia and was admitted to ICU. He rapidly developed multi-system organ failure (MSOF)including severe hepatitis with AST 13,950 U/L and ALT 10,000 U/L, pancytopenia (Hb 12.9 g/dL, WBC 1.7 K/uL, platelet 15,000 K/uL), acute kidney injury (Cr 6.61 mg/dL), and severe ARDS requiring mechanical ventilation. Abdominal ultrasonography showed splenomegaly. Blood HSV1 DNA PCR was positive with liver biopsy revealing viral inclusions consistent with HSV hepatitis. He had elevated ferritin > 100,000 ug/L and LDH > 2500 U/L. Bone marrow biopsy demonstrated hemophagocytosis and trilineage hematopoiesis. He met 6 of 8 diagnostic criteria for HLH per the HLH-2004 protocol. He received dexamethasone. Risks and benefits of HLH-specific therapy were considered in the setting of liver dysfunction and the decision was made to withhold etoposide and administer anakinra. He died of refractory septic shock and disseminated intravascular coagulopathy. DISCUSSION: Diagnosis of HLH can be challenging due to its rarity and the clinical picture may be initially attributed to sepsis in the presence of infection, as in our patient who had COVID-19 infection and HSV hepatitis. However, a ferritin level >10,000 ng/mL is 90% sensitive and 96 % specific for HLH, with very minimal overlap with sepsis, infections, and liver failure. Additionally, infection is a known trigger of HLH. Despite high mortality without therapy, survival can be significantly increased with HLH-specific therapy, such as etoposide. Treatment with etoposide in the setting of severe liver disease can raise concern because it is metabolized by the liver but it is an essential component of optimal therapy and can be considered in patients with hepatic dysfunction with dose reduction. CONCLUSIONS: Our case highlights the importance of maintaining a high index of suspicion for HLH in critically ill patients with MSOF and liver failure, despite an apparent infectious etiology. This may allow timely diagnosis, early referral to a specialist center and consideration of HLH-specific therapy such as etoposide despite liver dysfunction, to prevent high morbidity and mortality in this potentially fatal disease. Reference #1: Filipovich AH. Hemophagocytic lymphohistiocytosis (HLH) and related disorders. Hematology Am Soc Hematol Educ Program 2009;:127. DISCLOSURES: No relevant relationships by Abdul Khan No relevant relationships by Nehan Sher No relevant relationships by yuttiwat vorakunthada
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Background: With the COVID-19 pandemic, the demand and availability of telehealth in outpatient care has increased. Although use of telehealth has been studied and validated for various medical specialties, relatively few studies have looked at its role in gastroenterology despite burden of chronic diseases such as inflammatory bowel disease (IBD). Aims: To assess effectiveness of telehealth medicine in gastroenterology by comparing medication adherence rate for patients seen with telehealth and traditional in-person appointment for various GI conditions. Methods: Retrospective chart analysis of patients seen in outpatient gastroenterology clinic was performed to identify patients who were given prescription to fill either through telehealth or in-person appointment. By using provincial pharmacy database, we determined the prescription fill rate. Results: A total of 241 patients were identified who were provided prescriptions during visit with their gastroenterologists. 128 patients were seen through in-person visit during pre-pandemic period. 113 patients were seen through telehealth appointment during COVID pandemic. The mean age of patients in telehealth cohort was 42 years (57% male). On average patients had 10 prior visits with their gastroenterologists before index appointment, used for adherence assessment. 92% of patients were seen in follow-up, while 8% were seen in initial consultation. The majority of the patients in the telehealth cohort had IBD (89%), while the remaining 11% had various diagnoses, including functional GI disorder, gastroesophageal reflux disease, viral hepatitis, or hepatobiliary disorders. Biologic therapy was the most commonly prescribed medication (66.4%). 45 patients were provided either new medication or dose change, and 68 patients had prescription refill to continue their current medications. It took a mean of 18 days (SD = 16.2) for patients to fill their prescriptions. Prescription fill rate for patients seen through telehealth and in-person visit were 98.2% and 89.1% (P = 0.004) respectively. Patients seen through telehealth were 6.8 times more likely to fill their prescriptions compared to the in-person counterparts (OR 6.82, CI 1.51 - 30.68, P = 0.004). When we compared adherence rate while excluding biologic therapies, the prescription fill rate was 94.7% in telehealth group and 81.4% in in-person group (OR 4.11, CI 0.88 - 19.27, P = 0.056). Due to high level of adherence, statistical analysis comparing adherent and non-adherent groups was performed but yielded insignificant results. Conclusions: Medication adherence rate for patients seen through telehealth was higher compared to patients seen through in-patient visit in this study. Telehealth is a viable alternative for outpatient care especially for patients with chronic GI conditions such as IBD.
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Introduction: Sepsis is a common cause of morbidity and mortality with no gold standard diagnostic test for detecting sepsis. Blood cultures are a frequent diagnostic step but the results take at least 48 hours and timely recognition of infection and initiation of appropriate antibiotics remain crucial in the treatment of sepsis. Biomarkers thus come in handy for rapid diagnosis and risk stratification. Objectives: Primary objective: To assess the diagnostic and prognostic value of procalcitonin (PCT), interleukin-6 (IL-6), ferritin, and C-reactive protein (CRP) levels in differentiating between Gram-negative and Gram-positive sepsis patients. Secondary objective: To determine the relationship between serum PCT, IL-6, ferritin, and CRP levels and isolated sepsis pathogens. Materials and methods: We are conducting a cross-sectional study for a period of 2 years on 360 adult patients admitted in an intensive care unit (ICU) of a tertiary care hospital with sepsis or septic shock. Our exclusion criteria are patients with burns, suspected or documented non-bacterial infections, viral hepatitis, iron overload states, and active COVID-19 infection. We are using convenience sampling. Demographic details of patients are collected. Blood is drawn for estimation of the four aforementioned biomarkers as well as body fluids of the patient based on clinical suspicion are sent for microbiological evaluation on admission to ICU before administration of antibiotics. Based on the culture reports, patients are classified as culture-positive or culture-negative sepsis and the biomarkers in each group are analyzed for diagnostic and prognostic accuracy. The primary outcome of the study is the survival or death of the patient while the secondary outcome is the number of days of ICU stay. During the time of submission, only 25 patients had been recruited and an interim analysis is being conducted. Results: During the time of submission, only 25 patients had been recruited and an interim analysis is being conducted. The mean age of our patients was 57.16 years. The study population was predominantly males (20 subjects) with ten subjects of urosepsis, three with pancreatitis, two with pneumonia, and the remaining ten had a miscellaneous diagnosis. The mean values of the inflammatory markers were as follows: PCT = 16.672 (±24.3495), CRP = 85.8428 (±62.1224), IL-6 = 610.268 (±723.3846), and ferritin = 625.0832 (±628.5289). The p value of the biomarkers is <0.00001 and is significant at p < 0.05. The following combinations of biomarkers were found to be statistically significant - PCT with IL-6 (p = 0.00018), PCT with ferritin (p = 0.00012), CRP with IL-6 (p = 0.00116), and CRP with ferritin (p = 0.00079). The sensitivity of CRP and IL-6 was 100% while specificity was highest for PCT at 50%. Eight of the subjects had Gram-negative sepsis. The mean days of hospitalization were 19.92 days. Eight of the subjects died contributing to a mortality rate of 3.2 per 10 subjects. Conclusion: The combination of biomarkers reflects different aspects of sepsis pathophysiology and would be feasible to incorporate as a point of care testing. The biomarker panel that would provide diagnostic information for the investigation of a patient with suspected sepsis earlier than cultures is PCT with IL-6 and ferritin.
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Background and aims: Screening for oesophageal varices and surveillance for hepatocellular carcinoma (HCC) are advised for patients with cirrhosis but adherence to recommendations is poor. The study aimed to provide descriptive analysis of a new cirrhosis database and evaluate rates of surveillance in a large teaching hospital. Method: All patients diagnosed with advanced fibrosis/cirrhosis in our centre entered the database sequentially from April 2018. The service covers a population of 600000, with expected prevalence of 600 cirrhotic patients. The database-rather than clinic visits-became the primary means to monitor HCC surveillance/endoscopic screening requests. Subsequent adherence to recommendations was measured in 2021. Results: 841 patients entered the database over 3 years, with only 200 at inception-less than the predicted cirrhosis prevalence. 36 people died during follow-up and 5 left the area. Of the remaining 800 patients, median age was 60 years;40% female. 46% of patients had alcohol related disease, 21% non-alcoholic fatty liver disease, 14% viral hepatitis. 63% of the cohort had Childs-Pugh (CP) A or advanced fibrosis, 14% CP-B, 3% CP-C. 21% had no stage recorded. 157 patients (20%) were on primary prophylaxis for variceal bleeding. Of the remaining 643 patients, 237 (37%) were on active endoscopic surveillance and a further 100 (16%) had attended endoscopy in the past 3 years. 43 patients (7%) were overdue, 40 (6%) declined, and 30 (5%) had documented clinical decision not to proceed. 191 patients (24%) had no documentation about screening. 603 (78%) of appropriate patients were up to date with HCC surveillance with a further 105 (14%) awaiting scan, significantly more than our historically reported adherence of 50% (p = <0.0001). Conclusion: The database improved our knowledge of clinical characteristics of our patient population, and provided a way to readily monitor surveillance intervals. Most had appropriate HCC surveillance, surpassing our previous (or nationally reported) adherence rates. A quarter of patients had no documentation of variceal screening, highlighting an area for improvement. Given the rapid rise in cohort size, it is likely the database also reduces numbers lost to follow-up/surveillance in the event of clinic non-attendance, which may be particularly valuable in the post-Covid era of delayed appointments. This study shows the potential of a registry to improve care and outcomes in people with cirrhosis
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Background and aims: Malnutrition is a common comorbidity in cirrhotic patients and confers a poorer prognosis. Vitamin C (VC) is a micronutrient essential for human health. Vitamin C deficiency (VCD) can lead to scurvy and may impair immune and liver functions. Although previously thought to be rare in developed countries, VCD is now well described in patients with pneumonia, COVID19 and upper gastrointestinal bleeding (UGIB). The prevalence and clinical significance of VCD in cirrhosis remains poorly studied. Method: Patients with cirrhosis admitted to 3 metropolitan tertiary centres in Australia were prospectively included over a 10-month period in 2021. Fasting VC levels were collected on admission and we recorded demographic data and clinical outcomes. The primary outcomes were the prevalence of VCD (defined as VC level <23 mcmol/L) and severe VCD (SVCD), defined as <11 mcmol/L. Secondary outcomes included mortality, intensive care admission, length of stay (LOS) and rate of infection. Results: 117 patients were included. Mean age was 57.1 ± 13.9 years, 59.0% were male and 23.9% belonged to the lowest socioeconomic decile. The most common aetiologies of cirrhosis were alcohol (62.4%), viral hepatitis (24.0%) and non-alcoholic fatty liver disease (18.8%). Median MELD scorewas 29 (IQR 22–36) and Child Pugh (CP) grades were 12.8% A, 46.2% B and 41.0% C. Most patients (74.4%) were hospitalised with complications of decompensated cirrhosis, including ascites (59.0%), encephalopathy (31.6%) and variceal bleeding (11.1%). Median VC level was 34mcmol/L (IQR 16–55) and did not differ with age, gender, or aetiology of cirrhosis. Increasing CP grade correlated with significantly lower median VC levels (CP-A 46.0 mcmol/L vs. CPB 36.5 mcmol/L and CP-C 20.5 mcmol/L, p = 0.026). The prevalence of VCD and SVCD were 39.3% and 17.1% respectively. SVCD was more prevalent in patients with a body mass index <25 (28.3% vs 13.0%, p = 0.036). In-hospital mortality was 12.8% and did not differ by VCD status, however in the subgroup of patients presenting with UGIB, SVCD correlated with significantly higher mortality (50% vs 4.1%, p = 0.045). Bacteraemia was more frequent in patients with VCD (13.3% vs. 1.4%, p = 0.014) and SVCD (26.3% vs 2.1%, p < 0.001), which remained significant at multivariate analysis (OR for every 1mcmol/L increase in VC, 0.91 (95% CI: 0.83–0.99), p = 0.037). Overall infection rateswere higher in patients with SVCD (40.0% vs. 27.8%) although thiswas nonsignificant (p = 0.279). Median hospital LOS was 10 (IQR 6–18) days and did not differ by VCD status. (Figure Presented) Conclusion: VCD is common in hospitalised cirrhotic patients and prevalence increases with severity of liver disease. VCD increases the risk of infective complications and higher mortality was observed in patients with UGIB and SVCD. Further studies are required to assess the significance of VCD in cirrhosis and the impacts of VC replacement.
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The global burden of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections and coinfection represents a major public health concern, particularly in resource-limited settings. Elimination of HCV by 2030 has become foreseeable, with effective direct-acting antiviral oral therapies and the availability of affordable generics in low-and-middle-income countries (LMICs). However, access to oral nucleos(t)ide therapy for HBV remains critical and is limited outside the existing global HIV program platforms despite affordable prices. Prevention of mother-to-child transmission of HBV through scaling up of birth dose implementation in LMICs is essential to achieve the 2030 elimination goal. Most individuals living with HBV and/or HCV in resource-limited settings are unaware of their infection, and with improved access to medications, the most significant barrier remains access to affordable diagnostics and preventive strategies. The coronavirus disease 2019 pandemic interrupted hepatitis elimination programs, albeit offered opportunities for improved diagnostic capacities and raised political awareness of the critical need for strengthening health care services and universal health coverage. This review underpins the HBV and HCV management challenges in resource-limited settings, highlighting the current status and suggested future elimination strategies in some of these countries. Global efforts should continue to improve awareness and political commitment. Financial resources should be secured to access and implement comprehensive strategies for diagnosis and linkage to care in resource-constrained settings to fulfill the 2030 elimination goal.
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Introduction: Kratom (mitragynine speciosa) is a tree native to Southeast Asia that has both opioid, stimulant, and other unknown properties. It is currently legal in the United States and used for therapeutic and recreational purposes. There is a dearth of literature on kratom’s effects on the body. At least half of reported kratom exposures resulted in a serious medical outcome, including death (1). In contrast, there are no controlled clinical trials on safety and efficacy of kratom as a treatment (2). Case: A 32-year-old Caucasian, currently unemployed, unmarried, mother of two children presented intubated to the MICU from an outside hospital with acute fulminant hepatic failure in the setting of significant kratom use. The patient also presented febrile with intracranial hemorrhage, cerebral edema, GI bleeding, acute renal failure, and diffuse intravascular coagulation. Psychiatry was consulted for potential liver transplant candidacy. Her previous history included six years of opioid use and transition to kratom 1-2 years prior to admission, with recent ingestion up to twenty-five times the patient’s usual amount (up to 125mg). Pertinent positive labs included elevated troponin (0.4), transaminitis ( >11,000), elevated PT/PTT (99/52), D-dimer ( >20), hematuria, pyuria, serum ferritin, prolonged QTc (514), and hypoglycemia. Pertinent negatives included unrevealing serum ethanol, phosphatidylethanol, viral hepatitis, HIV, COVID-19, EBV, CMV, other viral panels, acetaminophen level, toxicology screen, and EEG. Imaging revealed interstitial pulmonary edema and diffuse cerebral edema. Given lack of published information on kratom, the team emergently listed the patient for liver transplant despite significant concern for kratom use disorder. Over the course of three days, the patient’s mental status and labs continued to worsen, ultimately resulting in death. Interventions pursued included dialysis, mechanical ventilation, intracranial pressure monitoring with pressure optimization, anticonvulsant therapy, antibiotic therapy, N-acetylcysteine, and other routine MICU care. Due to relatively unremarkable health before ingestion, lack of other significant events, and severe rapid decline, multidisciplinary team consensus cause of death was due to kratom ingestion causing “acute liver failure with hepatic coma”. Discussion: This case report will go into further detail on kratom by analyzing kratom’s mechanism of action, therapeutic use, known side effects including addictive potential, effects on the liver including acute fulminant injury, and current laws and regulations surrounding kratom in the United States with relevance to public health. This is relevant to psychiatrists in the general consult, transplant, and addictions services. References: 1. Post S, Spiller HA, Chounthirath T, Smith GA. Kratom exposures reported to United States poison control centers: 2011–2017. Clinical Toxicology. 2019 57:10,847-854. DOI:10.1080/15563650.2019.1569236 2. Prozialeck W. Update on the Pharmacology and Legal Status of Kratom. J of the AOA. 2016, 116, 802-809. DOI: https://doi.org/10.7556/jaoa.2016.156
ABSTRACT
Objective: Viruses are agents that can infect all kinds of living organisms, and the most important hosts are humans, animals, plants, bacteria and fungi. Viral diseases are responsible for serious morbidity and mortality worldwide, are a major threat to public health, and remain a major problem worldwide. The recently prominent Coronaviruses (CoVs) within this group belong to the Coronaviridae family, subfamily Coronavirinae, and are large (genome size 26-32 kb), enveloped, single-stranded ribonucleic acid (RNA ) viruses that can infect both animals and humans. The world has experienced three epidemics caused by betaCoVs in the last two decades: SARS in 2002-03, MERS in 2012, and COVID-19, first identified in 2019. COVID-19 continues to be our current health problem and studies on the subject continue. Result and Discussion: The term "antiviral agents" is defined in very broad terms as substances other than virus-containing vaccine or specific antibody that can produce a protective or therapeutic effect for the clearly detectable effect of the infected host. Nature has the potential to cure humanity's helplessness against viruses with many different plant species with strong antiviral effects. During the screening of plants with antiviral effects, focusing on plants used in folk medicine is of great importance in terms of maximizing the benefit to humanity - saving time and effort by dealing with valuable ancient knowledge on a scientific basis. In this review, viral diseases and the plants used in these diseases and determined to be effective are mentioned.
ABSTRACT
Objective: Viruses are agents that can infect all kinds of living organisms, and the most important hosts are humans, animals, plants, bacteria and fungi. Viral diseases are responsible for serious morbidity and mortality worldwide, are a major threat to public health, and remain a major problem worldwide. The recently prominent Coronaviruses (CoVs) within this group belong to the Coronaviridae family, subfamily Coronavirinae, and are large (genome size 26−32 kb), enveloped, single-stranded ribonucleic acid (RNA) viruses that can infect both animals and humans. The world has experienced three epidemics caused by betaCoVs in the last two decades: SARS in 2002−03, MERS in 2012, and COVID-19, first identified in 2019. COVID-19 continues to be our current health problem and studies on the subject continue. Result and Discussion: The term "antiviral agents" is defined in very broad terms as substances other than virus-containing vaccine or specific antibody that can produce a protective or therapeutic effect for the clearly detectable effect of the infected host. Nature has the potential to cure humanity's helplessness against viruses with many different plant species with strong antiviral effects. During the screening of plants with antiviral effects, focusing on plants used in folk medicine is of great importance in terms of maximizing the benefit to humanity - saving time and effort by dealing with valuable ancient knowledge on a scientific basis. In this review, viral diseases and the plants used in these diseases and determined to be effective are mentioned.
ABSTRACT
As the COVID-19 pandemic made its gruesome initial appearance in the first months of 2020, it initially appeared as though nothing could be more distant from this acute, dramatic, life - threatening condition, treated in intensive care units and heroically combated behind personal protective equipment, than fibromyalgia, a chronic pain syndrome treated in clinics by primary care physicians and rheumatologists. Only gradually, as the medical community became more accustomed to the manifestations and complications of COVID-19, did the more chronic aspects of the pandemic come to light with the evolving entity of LONG-COVID syndrome (1). This syndrome was initially treated by a broad spectrum of specialties including infectious disease specialists, pulmonologists, neurologists, with rheumatologists not taking a central role. As more clinical experience was accumulated however, a surprising overlap begins to emerge between LONG-COVID and conditions such as fibromyalgia and chronic fatigue syndrome, an overlap most obvious on a clinical level to rheumatologists well acquainted with the spectrum of fibromyalgia (2). On a clinical level, LONG COVID patients most frequently suffer from fatigue, exercise intolerance, as well as cognitive impairment, all symptoms which overlap with the chronic fatigue syndrome. Sleep disturbances, abdominal complaints, anxiety /depression and myalgia are also not unusual (3). In addition, autonomic dysregulation appears to play a role in LONG COVID (4), as in fibromyalgia. Notably, symptoms typical of fibromyalgia among LONG-COVID patients appear to be particularly common among patients with a previous history of chronic pain, and patients who were actually diagnosed with fibromyalgia before contracting COVID-19 appear to be prone to get worse (5). Notably, an association between fibromyalgia / chronic fatigue and other chronic viral diseases such as EBV/CMV, HIV and viral hepatitis has been well known before the COVID-19 era, so that viral infection has traditionally been considered among the triggers responsible for instigation the syndrome (6). Another aspect of clinical importance regarding the relationship between fibromyalgia and COVID-19 relates to the effect of vaccinations. While vaccinations have previously been speculated to have a causative role in fibromyalgia, mainly based on data relating to the gulf war syndrome, the robustness of this association is not clear. In an era of significant vaccine - hesitancy which often hampers effective attempts at controlling the pandemic, clear data regarding the safety and effectivity of COVID-19 vaccinations regarding fibromyalgia is necessary. Fascinating data has emerged indicating that patients suffering from LONG - COVID may actually have low grade persistent infection, with identification of viral antigens and RNA in tissue as long as one year after initial infection (7). While the general applicability of these findings is not yet clear, they raise the provocative possibility that similar viral vectors might be identifiable in tissues of patients suffering from chronic fatigue or fibromyalgia. Last but not least, the COVID-19 pandemic, including the social distancing measures associated with it, have taken a toll on patients suffering from fibromyalgia even when not personally infected (8). Reduced access to healthcare, lockdown and lack of exercise, anxiety and isolation may all play a role and should be considered by physicians caring for fibromyalgia patients in this era.