摘要
Introduction: HSV hepatitis is a rare cause of acute liver failure resulting in high morbidity and mortality with 74% progressing to death or liver transplant. Diagnosis is often delayed due to nonspecific symptoms, with the presence of characteristic rash in less than 50%. We present the case of a previously healthy non-pregnant woman who presented with acute liver failure from HSV-2 infection requiring transplant. Case Description/Methods: A 37-year-old woman presented to the ER with a 2-week history of fever, chills, and fatigue. She had been using acetaminophen 1 g q 3-4 hours for 1 week and reported longstanding alcohol use. She had normal mentation and no visible skin rashes. Labs showed ALT 3000, AST 5070, bilirubin 3.0, ALP 962. INR was 1.38 with an undetectable acetaminophen level. Tests for SARS-CoV-2, influenza, and Streptococcus were negative. She was started on N-acetylcysteine and transferred for consideration of liver transplant due to presumed acetaminophen-induced liver toxicity. On arrival the patient was alert but confused and unable to give an accurate history. Exam showed no oral, body or vaginal rash. Viral serologies showed CMVPCR -, EBV detected < 500, HIVRNA -, HCVRNA and HBVDNA -, HSV1 ND, HSV2 detected. Acyclovir (IV 10 mg/kg, 3 times/day) was started. Over 24 hours, mental status continued to decline requiring intubation. Liver biopsy revealed 70% submassive non-zonal necrosis with mixed portal inflammation and diffuse microvesicular steatosis, with no viral cytopathic effect. She underwent an uncomplicated orthotopic liver transplantation the next day. Explanted liver pathology showed submassive hepatic necrosis with staining positive for HSV. She continued on iv acyclovir and was discharged home. HSV remains detectable 25 days following transplant. At follow up patient described a diffuse macular rash which was present and resolved for 36 hours prior to hospital presentation. Discussion: This case illustrates the insidious onset and rapid clinical deterioration that can occur with HSV hepatitis. Given a high mortality rate, empiric initiation of IV acyclovir should be considered in patients with quantifiable HSV viremia and a viral prodrome. Our patient's non-characteristic rash resolved prior to evaluation, masking clinical suspicion for HSV hepatitis in the setting of acetaminophen and alcohol use. Patients may have clinical and histologic features suggesting drug-induced liver injury;thus, a broad differential diagnosis is key for early recognition and effective treatment.
摘要
INTRODUCTION: An emerging body of literature has shown an association between obesity and negative COVID-19 patient outcomes. However, most of these studies have been limited in scale and are not focused on hospitalized patients. Our study aims to report characteristics and outcomes associated with obesity in a large cohort of COVID-19 patients who were admitted during the peak of this pandemic. METHODS: We performed a retrospective single center study at a large tertiary care hospital. All index admissions of adult patients with confirmed COVID-19 between 3/1 and 4/30/2020 were included. A manual chart review was performed to collect data on baseline patient characteristics, medical comorbidities, and clinical outcomes. Patients were stratified into obese and non-obese cohorts for comparison. SAS 9.4 was used for analysis. RESULTS: A total of 1983 patients met our inclusion criteria of which 1031 (51.9%) were obese and 952 (48.9%) were non-obese. Table 1 shows differences in baseline characteristics between these cohorts. Obese patients were younger (58.2 vs. 69.9;P < 0.001), more likely to be female (55% vs. 45%;P < 0.001) and a higher proportion were African American (66% vs. 52%;P < 0.001) compared to non-obese patients. Obese patients were also more likely to be diabetic (41% vs. 35%;P = 0.01) and have obstructive sleep apnea (15% vs. 5%;P < 0.001) and less likely to have cardiovascular disease (25% vs. 33%;P < 0.01) and malignancy (5% vs. 10%;P < 0.01) (Table 2a). Obese patients were found to have lower overall mortality compared to non-obese patients (15% vs. 25%;P < 0.001) however a logistic regression model revealed that this mortality difference was no longer significant when adjusted for patient age (OR 1.05, P = 0.685). This age-adjusted model also demonstrated increased odds of ICU admission (OR 1.39, P = 0.0044) and intubation (OR 1.40, P = 0.0096) in obese patients (Table 2b). There was a strong negative correlation (r2 = 0.2076, P < 0.001) between BMI and age among patients requiring ICU admission (Figure 1). CONCLUSION: Our study suggests that obesity may predispose younger patients with COVID-19 to be hospitalized for their illness. Although obese patients do not have an increased mortality rate, they are at higher risk for requiring ICU admission and intubation during their hospital stay. Recognizing that obesity impacts morbidity in this manner allows medical providers to triage and manage these patients more effectively earlier in their clinical course. (Table Presented).
摘要
Background: There is increasing evidence suggesting that liver dysfunction is a risk factor for severe COVID-19 illness However, due to the low prevalence of liver disease and cirrhosis in the general population, larger studies looking at the impact of these conditions have utilized data from international registries which do not necessarily reflect the US population. Our study aims to assess the association between chronic liver disease and COVID-19 clinical outcomes across a single large inpatient cohort Methods: We performed a retrospective single-center study at a large tertiary care hospital All index admissions of adult patients with confirmed COVID-19 between 3/1/2020 and 4/30/2020 were included A manual chart review was performed to collect data on baseline patient characteristics, medical comorbidities, and clinical outcomes Patients with chronic liver disease (CLD) and cirrhosis were compared to the control group, who had no known underlying liver disease SAS 9 4 was used for analysis Results: A total of 1935 patients met our inclusion criteria of which 1869 (96 6%) had no underlying liver disease, 66 (3 4%) had CLD, and 21 (1 1%) had cirrhosis Table 1 shows baseline patient characteristics There were a higher proportion of males in the CLD and cirrhosis cohorts compared to the control group (67% and 76% vs 50%;p=0 0105) Patients with cirrhosis and chronic liver disease also had a significantly lower average BMI compared to the control group (25 8 and 27 3 vs 31 8;p=0 002) There was no difference in comorbidities between all three cohorts. Patients with cirrhosis had a significantly higher mortality (RR 2 1 [95% CI 1 33-3 62;p=0 0022]) compared to non-cirrhotics There was also a trend towards increased 30-day readmission in the cirrhotic cohort (RR 2 35 [95% CI 0 86-6 42];p=0 0950) however no difference in rate of ICU admission or intubation Patients with CLD did not have an increase in mortality, ICU admission, intubation, or 30-day re-admission compared to the control group Conclusion: Our study demonstrates that cirrhosis is associated with increased mortality in COVID-19 while chronic liver disease in the absence of cirrhosis does not confer the same degree of clinical risk Future studies performed on a larger scale should evaluate how decompensated disease and MELD score may impact this risk profile.(Table Presented).
摘要
Background: Based on current literature there appears to be a high prevalence of liver injury (LI) in patients with COVID-19 However, there are limited large scale studies on risk factors, morbidity, and mortality associated with LI in these patients We aim to determine risk factors and outcomes of patients hospitalized with COVID-19 and LI Methods: We performed a retrospective single-center study at a large tertiary care hospital. All index admissions of adult patients with confirmed COVID19 between 3/1 to 4/30/2020 were included Data on baseline characteristics and clinical outcomes was collected during manual chart review Mild elevation in LFTs (MEL), defined as peak levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and total bilirubin (TB) above upper limit of normal (ULN) but lower than the threshold for LI. LI was defined as peak ALT/AST three times ULN and/or peak ALP/TB two times ULN ULN threshold values of ALT 52, AST 35, TB 1 2, ALP 140 were used Both cohorts were compared with our control group, who had normal LFTs at presentation and throughout the hospitalization SAS 9 4 was used for analysis Results: A total of 1935 patients were included of which 507 (26 2%) had normal LFTs, 1030 (53 2%) had MEL, and 397 (20 5%) had LI Males were more commonly found in the MEL (p=0 0004) and LI groups compared to control (p< 0001) Patients in the MEL cohort were older (p=0 0005) African Americans were more likely to develop LI (p=0 0318) There was no difference in comorbidities between all groups Among patients with LI, 241 (61%) had a hepatocellular pattern, 20 (5%) had a cholestatic pattern, and 135 (34%) had a mixed pattern Patients with LI had an increased risk of mortality (RR 4 26 [95% CI 3 12, 5 81;p< 0001]), ICU admission (RR 5 52 [95% CI 4 07, 7 49;p< 0001]), intubation (RR 11 01 [95% CI 6 97, 17 34]);p< 0001) and 30-day readmission (1 81 [95% CI 1 17, 2 80;p< 0076]) (Table 2, Figure 1) compared to the control group Conclusion: Our study demonstrates that patients with COVID-19 who present with LI have a significantly increased risk of mortality, mechanical ventilation, ICU admission, and 30-day re-admission compared to patients with MEL and normal LFTs This information is important to appropriately manage COVID-19 patients Further research looking at risk prediction models and pooling multi-center data should include liver injury as a key variable.