Gallbladder Edema Research Articles

Acute necrotic hepatotoxicity caused by Melanthera latifolia (Asteraceae) in cattle

This study aims to report a spontaneous and experimental intoxication in cattle by Melanthera latifolia (Asteraceae) for the first time, and to describe its epidemiological, clinical, and pathological findings. An outbreak of acute toxic hepatopathy in cattle occurred from December of 2021 to January of 2022 in a beef cattle farm from Rio Grande do Sul state, Southern Brazil, and resulted in 94 deaths from a herd of 430 animals. At necropsy, lesions consisted of enhanced lobular pattern of the liver, transmural gallbladder edema, and hemorrhages on the surface of multiple organs. The main microscopic lesion was marked hepatocellular necrosis in the centrilobular region associated with hemorrhage and infiltration of neutrophils. During the outbreak, multiple specimens of M. latifolia were noted in the paddocks where affected cattle were grazing and many showed signs of consumption. No other known acute hepatotoxic plants were found. Two 12-month-old steers were experimentally intoxicated with a single oral dose of the fresh plant (flowers, leaves, and less fibrous stalks). One bovine ingested a dose of 10 g/kg and was euthanized after 48 h, and the other ingested 15 g/kg and was euthanized 17 h later. Clinical signs, macroscopic, and microscopic lesions in both animals were similar to those observed in the spontaneous cases. Thus, this study demonstrates that M. latifolia was the cause of the outbreak of acute toxic hepatopathy with significant mortality in cattle. M. latifolia nor any plant of the genus Melantherahad ever been reported as toxic.

Cholecystalgia: An Atypical Presentation of Congestive Heart Failure in a New Diagnosis of Alcohol-Induced Cardiomyopathy

Right upper quadrant (RUQ) pain is a frequent presenting symptom in the emergency department, and gallstone-induced acute cholecystitis is one of the main causes; in addition, RUQ pain can be a consequence of several other conditions. Although rare, it may also indicate cholecystalgia from gallbladder edema, which is usually related to other conditions, such as congestive heart failure (CHF), alcoholic and nonalcoholic liver cirrhosis, acute viral or drug-induced hepatitis, renal failure, and hypoproteinemia. We present a case of cholecystalgia resulting from gallbladder edema in a patient with a newly diagnosed alcohol-induced cardiomyopathy without the common CHF signs and symptoms.

Complications of Dengue Infection in Admitted Patients at Rehman Medical Institute: A Retrospective Study

Dengue infection is an arthropod-borne Flavivirus infection that spread through female mosquitoes (Genus Aedes). Dengue infection is a major health challenge in the tropical and subtropical parts of the world. Methods: This is a retrospective study conducted at Rehman Medical Institute (RMI). Data were retrieved from the Clinical test reports of confirmed dengue infection during the timeline; June to October (monsoon season) of the year 2021. Clinical as well as biochemical parameters were considered during the data assembling and assessment process. Results: Out of 156 suspected cases of dengue infection, 94 were confirmed through laboratory testing. 83 patients tested positive with Dengue NS1 antigen while after re-screening 94 cases (54 male patients and 40 female patients) were confirmed by Dengue serology (IgM antibodies) test. According to our study results, among a set of varied symptoms, malaise (99%) was the most common clinical presentation, along with 94% fever. Some patients with severe dengue infection developed serious illnesses including encephalopathy (8.5%), hypokalemic paralysis (6.3%). Moreover, 8.5% of patients were presented with Cholecystitis seen as Edematous Gallbladder wall on ultrasound scans, and 1% of the patient developed acute Pancreatitis. Fortunately, no casualty was reported due to dengue at RMI-General hospital. Conclusion: In our setup, Fortunately, no death was reported but a substantial number of patients suffered from serious complications such as neurological and hemorrhagic conditions along with communal clinical manifestations. Despite much reported data still, further investigation and monitoring are needed to comprehend the contemporary condition of the prevalence of dengue infection in Khyber Pakhtunkhwa, Pakistan.

An Observational Study Of Dengue Induced Hepatic Dysfunction Ina Tertiary Care Hospital Of Gkgh Bhuj

INTRODUCTION: Dengue infection is a major health problem worldwide including our country. Globally the incidence of Dengue has grown dramatically in the recent years. Every year during the monsoon months and later, many parts of the country witness outbreak of dengue infection. 2020 was no exception and we experienced an outbreak of this vector borne disease in Bhuj. An analysis of these patients revealed that in addition to the classical features of fever, body ache, rash and thrombocytopenia and bleeding tendency, there were other features such as liver dysfunction including a preferential rise of SGOT, hepatomegaly, splenomegaly, ascites, gallbladder wall edema and pericholecystic fluid collection.OBJECTIVE: To study clinical, biochemical and radiological changes in the liver of patients with Dengue fever.METHOD: observational and cross-sectional study was conducted on a 50 suspected cases of Dengue fever admitted and diagnosed at GKGH hospital Bhuj in October 2020. Detailed history, clinical examination, biochemical parameters, radiological investigation for liver function was done in all patients. All patients were treated as per NVBDCP guidelines. RESULTS: all patients in our study had hepatic dysfunction in the form of elevated SGOT above normal limits. CONCLUSIONS: Our study shows that there are certain features of Dengue that are not known to be usually associated with it. The presence of raised liver enzymes in all patients (SGOT > SGPT), ascites, hepatomegaly, splenomegaly, and gallbladder edema and pericholecystic fluid collection.

An Unusual Case of Haemobilia

Introduction: Haemobilia a rare cause of acute abdomen presents with Quincke’s triad: right upper quadrant pain, jaundice and gastrointestinal bleeding. Hemorrhagic cholecystitis is a rare cause of haemobilia. Case Presentation: A 30 year-old gentleman presented with right upper quadrant pain for 5 days, associated with fever, vomiting and jaundice. Patient was pale and icteric and right hypochondrium was tender with palpable gallbladder. His hemoglobin was 7.7 gm/dl with deranged liver function test (LFT). Abdominal ultrasonography demonstrated edematous and contracted gallbladder wall with echogenic lesion within the lumen. Computed tomography (CT) scan of abdomen revealed a mildly distended gallbladder, bilateral intrahepatic biliary radical dilatation and dilated common bile duct (CBD) with hyperdense sludge in the gallbladder and CBD. Patient developed per rectal bleeding on the fourth day of admission. Upper GI endoscopy showed blood pooling from ampulla of Vater. Abnormal blushing of gallbladder wall with abnormal enhancement at neck of gallbladder arising from cystic artery, was noted on angiography, suggestive of hemorrhagic cholecystitis. During surgery thickened gallbladder wall, engorged cystic artery and blood mixed with clot was seen in the gallbladder lumen. Cholecystectomy with choledochoscopy was performed. Choledochoscopy demonstrated normal extrahepatic biliary channel. Post-operative period was uneventful, blood hemoglobin level was static and LFT improved. Patient was discharged on fourth post-operative day. Conclusions: Haemobilia can be fatal condition hence mandates urgent diagnosis and treatment. Hemorrhagic cholecystitis is not to be forgotten as a cause of haemobilia.

Port site metastases a year after initial laparoscopic cholecystectomy. Should the use of retrieval bags during laparoscopic cholecystectomy be the new gold standard?

Port site metastases a year after initial laparoscopic cholecystectomy. Should the use of retrieval bags during laparoscopic cholecystectomy be the new gold standard?

A study on predictors of severe dengue in pediatric patients in a tertiary care hospital in Telangana

Background: Dengue is an emerging arthropod borne disease with increasing incidence in recent years in several countries, especially India. Early recognition of progression of disease helps in triage and timely management of fluids to decrease mortality. Objective: The objective of the study was to identify the predictive factors for severe dengue in pediatric patients for hospitalization for close monitoring. Methods: This was a prospective observational study conducted in the department of pediatrics in a tertiary care hospital in Mahbubnagar from June 2019 to May 2020. One hundred and four children between the age group of 0 and 15 years with probable dengue symptoms who were willing to get admitted were included in the study cohort. Thorough history and clinical examination, basic laboratory investigations such as complete blood picture, hematocrit, liver function tests, renal function tests (RFTs), serum electrolytes, serum ferritin, and coagulation profile were done as needed. All the patients were grouped into two groups – non-severe dengue (dengue fever without warning signs and dengue fever with warning signs) and severe dengue as per the World Health Organization guidelines. All the variables were analyzed using SPSS software. Results: Out of 104 confirmed cases, majority of the admissions were in 5–10 years age group (51.9%). Male children were 61.5%. Mean duration of hospitalization was 4.79±2.96 days. Fever (97.1%) was the most common symptom followed by anorexia (86.5%) and lethargy (82.7%). Symptoms such as lethargy, vomiting, abdominal pain/epigastric tenderness, epistaxis, edema, and altered sensorium were more commonly associated with severe dengue. Hepatomegaly (53.9%) was the most common clinical sign followed by epigastric tenderness (58.7%). Hepatomegaly, splenomegaly, ascites, gallbladder edema, pleural effusion, low pulse pressure, hypotension, oliguria, and significant gastrointestinal bleeds were more common in severe dengue group. Platelet count <50,000/mm3, increase in hematocrit more than 20% from baseline, raised transaminases, raised ferritin, decrease in serum sodium, decrease in serum albumin, abnormal coagulation profile, and abnormal RFTs were significantly associated with severe dengue. Mean platelet recovery time was 3–5 days. Conclusion: Dengue is a dynamic disease and progression of dengue with or without warning signs into severe dengue can be appropriately identified by close monitoring of certain clinical signs and symptoms.

Systemic dengue infection associated with a new dengue virus type 2 introduction in Brazil \u2013 a case report

BackgroundDengue infection is caused by an arbovirus with a wide range of presentations, varying from asymptomatic disease to unspecific febrile illness and haemorrhagic syndrome with shock, which can evolve to death. In Brazil, the virus circulates since the 1980s with many introductions of new serotypes, genotypes, and lineages since then. Here we report a fatal case of dengue associated with a Dengue virus (DENV) lineage not detected in the country until now.Case presentationThe patient, a 58-year-old man arrived at the hospital complaining of fever and severe abdominal pain due to intense gallbladder edema, mimicking acute abdomen. After 48 h of hospital admission, he evolved to refractory shock and death. DENV RNA was detected in all tissues collected (heart, lung, brain, kidney, spleen, pancreas, liver, and testis). Viral sequencing has shown that the virus belongs to serotype 2, American/Asian genotype, in a new clade, which has never been identified in Brazil before. The virus was phylogenetically related to isolates from central America [Puerto Rico (2005–2007), Martinique (2005), and Guadeloupe (2006)], most likely arriving in Brazil from Puerto Rico.ConclusionIn summary, this was the first fatal documented case with systemic dengue infection associated with the new introduction of Dengue type 2 virus in Brazil during the 2019 outbreak.

A case of elevated carbohydrate antigen 19-9 with a benign cause

Serum carbohydrate antigen 19-9 (CA 19-9), a marker of malignant tumors, is generally slightly elevated in benign conditions. We report a case of cholecystitis with perforated gall bladder with significantly elevated level of serum CA 19-9 based on abdomen computed tomography and intra operative findings. A 70 years diabetic and hypertensive female presented with right hypochondriac pain associated with occasional itching and nausea without vomiting with markedly raised CA 19-9 (1554 U/ml) with CECT abdomen suggestive of perforated gall bladder with cholecystitis. Patient electively operated for open cholecystectomy and per operative findings were distended gall bladder with multiple calculi within with edematous gall bladder wall and adhesions between gall bladder and omentum and colon. Gall bladder removed and biopsy suggestive of chronic calculus cholecystitis. On post-operative day 5th and 7th CA 19-9 was repeated twice and drastic fall to 5 U/ml and 12 U/ml respectively. Chronic calculus cholecystitis with high elevation of CA 19-9 is rare.

Gall Bladder Wall Thickening in Dengue Fever - Aid in Labelling Dengue Hemorrhagic Fever and a Marker of Severity.

IntroductionDengue fever is a mosquito-borne viral disease spread by the bite of the Aedes aegypti mosquito. Dengue epidemics have contributed to a great economic burden, especially in South-East Asia. This study aimed to determine gall bladder wall thickness (GBWT) in patients with dengue fever, assess its sensitivity and specificity to identify dengue hemorrhagic fever, and also compare gall bladder wall thickening (GWBT) with platelets, hematocrit, and leucocyte count.Materials and methodsThis prospective observational study was conducted in the dengue ward of Benazir Bhutto Hospital, Rawalpindi, Pakistan, from September 2019 to January 2020, i.e., four months. Patients admitted to the dengue ward diagnosed as seropositive and provided consent were enrolled into the study. Laboratory investigations (blood complete picture, liver function tests, renal function tests) were collected and recorded. Ultrasonography was performed on admission and subsequently during a hospital stay. Patients were divided into two groups: those with gall bladder wall thickness ≤ 3mm and ˃3mm. All data were entered and analyzed on SPSS version 24 (IBM Inc., Armonk, USA).ResultsOut of 180 patients, 122 (67.8%) were male, and 58 (32.2%) female. The mean age was 33 ± 13 years. One hundred and six patients (58.9%) were diagnosed with dengue fever, 68 (37.8%) - dengue hemorrhagic fever, and six (3.3%) - dengue shock syndrome. The most common finding was gall bladder wall thickness ˃3mm (69/180; 38.3%) followed by ascites (38.1%). Sixty-two patients out of 69 (89.9%) with GBWT ˃3mm were managed as dengue hemorrhagic fever (p=0.000). Alanine transaminase (ALT), platelet, and total leukocyte count (TLC) were associated positively with an edematous gall bladder wall (p<0.005). The mean gall bladder wall thickness for dengue hemorrhagic fever was 6.4mm ± 2.5 mm. A GBWT value of 3.5mm was found to have 94.6% specificity and 91.2% sensitivity.ConclusionGall bladder wall edema is strongly correlated with dengue hemorrhagic fever. Hence it should be assessed in all patients with dengue fever.

MASKED SEPSIS DUE TO ACUTE CHOLECYSTITIS IN A PATIENT WITH CARDIOPULMONARY DISEASE LEADING TO SEPTIC SHOCK: A CASE REPORT

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Sepsis is a primary cause of death in nearly 23.5% of chronic heart failure patients. The relationship between acute cholecystitis and cardiovascular disease is vague but there have been few studies suggesting cholecystocardiac link. Here we describe a similar case that presented as pulmonary edema and myocardial ischemia. CASE PRESENTATION: 81-year-old male with past medical history of myocardial infarction, chronic obstructive pulmonary disease, hypothyroidism, hypertension, hyperlipidemia presented to the emergency department with worsening exertional dyspnea for the past 3 days. On physical examination he was afebrile, tachycardic, hypoxic requiring 4L oxygen. Chest auscultation revealed bibasilar rales. Electrocardiogram showed ST segment depression in lateral leads and troponins were elevated at 1.56. Labs showed mild leukocytosis, BNP 1658, Creatinine 1.8 and normal hepatic panel. Chest X-Ray suggested pulmonary edema for which he was diuresed. He was started on heparin drip. Echocardiogram showed reduced ejection fraction of 40%. Cardiac catheterization showed multivessel disease and moderate pulmonary hypertension. Coronary artery bypass surgery was recommended. Next day he developed mild periumbilical pain, which later moved to his right upper quadrant. CT abdomen showed cholelithiasis with pericholecystic inflammation. Cholescintigraphy confirmed acute cholecystitis. Patient started becoming more dyspneic and pulmonary edema worsened. He became hypotensive and febrile. Sepsis bundle was initiated including blood cultures, broad spectrum antibiotics and intravenous fluids. Patient was intubated and transferred to critical care unit. He required multiple pressors. Continuous hemodialysis was started for metabolic acidosis. Blood cultures revealed gram negative bacteremia. Unfortunately, the patient could not be saved. DISCUSSION: Gallbladder edema may be a response to the ischemia caused by cardiac instability. The exact mechanism linking acute cholecystitis to extracholecystic diseases is unknown, but it is likely due to an increase in portal venous pressure along with a decrease in plasma oncotic pressure. Chronic cardiopulmonary diseases and aging can cause immune-senescence that may increase the risk of sepsis which sometimes does not meet SIRS criteria. These patients, especially when on betablockers, cannot meet increased metabolic demands. Irritation and spasticity of the gallbladder can create reflex stimuli through the autonomic pathways, which leads to temporary alteration in coronary blood flow. CONCLUSIONS: Acute cholecystitis may coexist with or be misdiagnosed as a cardiovascular disorder. Looking for signs of end organ dysfunction or subtle vital sign irregularities may help identify older patients who are on their way to decompensation and allow us to intervene earlier with appropriate investigations and treatment which may lead to the prevention of fatal events. Reference #1: Ozeki M, Takeda Y, Morita H, et al. Acute cholecystitis mimicking or accompanying cardiovascular disease among Japanese patients hospitalized in a Cardiology Department. BMC Res Notes. 2015;8:805. Published 2015 Dec 19. doi:10.1186/s13104-015-1790-8 Reference #2: Walker AMN, Drozd M, Hall M, et al. Prevalence and Predictors of Sepsis Death in Patients With Chronic Heart Failure and Reduced Left Ventricular Ejection Fraction. J Am Heart Assoc. 2018;7(20):e009684. doi:10.1161/JAHA.118.009684 Reference #3: Meelu OA, Baber U, Theodoropoulos K, Mennuni MG, Kini AS, Sharma SK. Acute cholecystitis and myocardial infarction: a case study with coronary involvement. Clin Case Rep. 2016;4(8):793-796. Published 2016 Jul 13. doi:10.1002/ccr3.621 DISCLOSURES: No relevant relationships by Aditya Bansal, source=Web Response No relevant relationships by Hina Farrukh, source=Web Response No relevant relationships by sreeja sompalli, source=Web Response

S2509 Aortic Dissection - A Rare Cause of Acute Liver Failure

INTRODUCTION: Acute liver failure (ALF) is a medical emergency which needs to be treated urgently. An atypical presentation might delay appropriate medical care. ALF as a result of aortic dissection presents atypically, and requires high clinical suspicion. CASE DESCRIPTION/METHODS: A 37-year-old female was admitted for deranged liver function test (LFT) associated with her first onset of complex generalized tonic clonic seizure. She had no past medical history. There were no family history of seizure or liver disease, in particular Wilson’s disease or hemochromatosis. There was no recent acetaminophen or excessive alcohol consumption. Upon admission, her blood pressure was 99/75 mmHg and there were no clinically detectable jaundice, hepatic flap, Kayser-Fleischer rings or chest pain. Her transaminases showed a hepatitic pattern of deranged LFT (ALT 388 U/L and AST 378 U/L with normal serum bilirubin, ALP and INR). Abdominal Ultrasound excluded the presence of liver cirrhosis or biliary obstruction. Serologies for viral hepatitis (A, B, C, E; EBV and CMV) and anti-liver panel were all negative. Computed Tomography (CT) of the brain excluded intracranial bleeding or mass. Chest radiography showed soft-tissue opacity over right upper mediastinum (Figure 1a). ECG showed sinus tachycardia. Urgent bedside echocardiography excluded acute myocardial infarction and valvular heart disease. Within 12 hours after admission, she started to developed features of ischemic hepatitis and acute liver failure (new asterixis, prolonged INR of 1.7, worsening LFT with ALT 3430 U/L, AST 3000 U/L, bilirubin 170umol/L). She also developed oliguric AKI. Intravenous N-acetylcysteine was given in view of early hepatic encephalopathy and rapidly progressing acute liver failure. While she had no chest pain, her rising serum troponin and widened mediastinum prompted an urgent CT Aortogram. The CT Aortogram showed a 4.3cm dilatation of the ascending thoracic aorta with acute hemopericardium and cardiac tamponade (Figure 1b). She underwent an emergent ascending aorta and aortic arch repair and temporary renal dialysis. Both her kidney, liver and neurological function recovered following surgical repair. DISCUSSION: This case highlighted the importance of prompt identification of acute aortic dissection as the etiology of fulminant acute liver failure. Delayed or missed diagnosis could have been catastrophic. The presence of neurological sequelae very early in the clinical presentation is a harbinger for an ischemic cause.Figure 1.: Chest X-ray showed a soft tissue opacity over the upper right mediastinum. This was further delineated on CT Aortogram to be an ulcerated ascending aorta dilatation.Figure 2.: Patchy diffuse hypoenhancement of the liver, gallbladder edema and ascites were seen on CT.

Abstract 329: Cholecystalgia: an Atypical Presenting Symptom of Congestive Heart Failure

Acute acalculous cholecystitis is defined as acute inflammatory disease of the gallbladder without evidence of gallstones or cystic duct obstruction. Imaging studies typically show a distended acalculous gallbladder with thickened walls. Heart failure is well known to cause congestive hepatopathy and can be associated with isolated gallbladder edema which is often difficult to differentiate from acalculous cholecystitis. We present a case of cholecystalgia secondary to isolated gallbladder edema without hepatic congestion in a patient with non-ischemic cardiomyopathy mimicking the presentation of acalculous cholecystitis. A 46-year-old female with a past medical history of recently diagnosed non-ischemic cardiomyopathy during a prior hospitalization. Echocardiogram showed biventricular heart failure with EF of 15 to 20% with severe left and right ventricular dilatation and global hypokinesis. Left heart catherization showed no angiographic evidence of coronary artery disease and right heart catheterization demonstrated pulmonary hypertension secondary to left heart disease. She left against medical advice and was non-compliant with her medications. Approximately one month later, she presented with shortness of breath and orthopnea. On physical examination, jugular venous distention, S3 gallop, diffuse crackles and anasarca were noted. Labs showed BNP of 12,735. Chest CT revealed cardiomegaly and diffuse interstitial edema with bilateral pleural effusions and no signs of pulmonary embolus. Metoprolol and bumetanide were initiated for management of her acutely decompensated congestive heart failure. Several days after admission, she developed severe sharp RUQ pain associated with nausea and vomiting. She was tachypneic, diaphoretic with severe tenderness in the RUQ. Abdominal ultrasound revealed no signs of congestive hepatopathy but revealed a diffuse, edematous thickening of the gallbladder wall without evidence of stones. Hepatobiliary scintigraphy revealed preserved gallbladder function with an EF of 88%. The remainder of her care was focused on optimization of the patient’s congestive heart failure with complete resolution of her symptoms. Acute decompensation of congestive heart failure can result in an increase in pulmonary or systemic venous pressure, which may result in vascular congestion. The vascular distention can lead to isolated distention of the gallbladder wall that can mimic symptoms of acalculous cholecystitis. In such patient’s cholecystectomy or percutaneous cholecystostomy is not warranted. Radiographic evidence and symptoms usually resolve with optimization of congestive heart failure treatment. This case details the under-recognized presentation of secondary cholecystalgia in a patient with acute RUQ pain and underlying congestive heart failure.

Clinico-laboratory profile and outcome of dengue fever among children attending a tertiary care hospital of rural Telangana, India

Background: Dengue is a self-limiting, vector-borne disease transmitted by Aedes mosquito, causing a major public health threat globally. The objective of this study is to assess the clinical profile and outcome of the dengue infection in children less than 14 years of age September 2018 to August 2019 at the Pediatric Department of S.V.S. Medical College, the tertiary care hospital in Mahabubnagar, Telanagana.Methods: Prospective study of 82 hospitalized children of &lt;14 years with the diagnosis of dengue illness. Children with diagnosis of dengue were classified further in to two groups as per WHO guidelines, Non-severe dengue fever (probable dengue, dengue with warning signs) and ‘Severe Dengue’ (Dengue Haemorrhagic Fever and/or Dengue Shock Syndrome (DHF/DSS). A separate questionnaire form used for documenting clinical history, laboratory parameters. Haematological parameters were noted, chest x-ray, ultra-sonogram in required cases was done. Children were managed as per WHO protocol. The outcomes of the cases were mentioned as discharge, left against medical advice and death.Results: A total of 82 children with dengue were divided in to 55(67%) non severe dengue and 27(33%) severe dengue with males 56(68.2%) and females 26(31.7%). The most common age of presentation was between 6-10 years 34(41.5%). Fever 73(89%) was the most common presenting symptoms. Pleural effusion and hepatomegaly were the commonest clinical findings 28(34.1%) each, which were more among the severe dengue patients. Gall bladder edema 29(35.3%) was the most common ultra-sonogram finding. Significant elevation of transaminases (SGOP, SGPT) was seen in 39(47.5%). Severe thrombocytopenia was observed in 22(26.8%) children. Management was by administration of colloids and crystalloids.Conclusions: Dengue is a global problem. Presenting features include high grade fever, vomiting, abdominal pain, skin rash. Early recognition of symptoms and proper management can reduce the mortality.

1396 Viral Acalculous Cholecystitis: A Rare Extrahepatic Manifestation of Hepatitis A

INTRODUCTION: Hepatitis A (HAV) is the most common form of acute viral hepatitis worldwide with an incidence of 0.6 reported cases per 100,000 population in the United States. Typical clinical symptoms include nonspecific prodromal symptoms such as fever, malaise, weakness, anorexia, nausea, vomiting and abdominal pain. Atypical features of HAV include recurrent hepatitis, prolonged cholestasis and extrahepatic manifestations. Acalculous cholecystitis (ACC) is an extremely rare extrahepatic manifestation of HAV. We present a unique case of acute hepatitis A presenting as ACC in an adult male with IV drug use. CASE DESCRIPTION/METHODS: A 50 year old male with a history of active IV heroin use and treated hepatitis C presented with nausea and RUQ abdominal pain for 3 days. On admission, laboratory findings were remarkable for AST of 2574 U/L, ALT of 3214 U/L, ALP 321 U/L and total bilirubin of 4.0 mg/dl. On physical examination patient was afebrile and hemodynamically stable with normal bowel sounds, soft abdomen, mild RUQ tenderness to deep palpation and Murphy's sign negative. CT abdomen demonstrated an edematous gallbladder wall with mild pericholecystic fluid and fat stranding, CBD diameter 4.0 mm (Figures 1 and 2). General Surgery believed his overall clinical picture to be due to acalculous cholecystitis and recommended non-operative management. Patients IgM Hepatitis A returned positive, Hepatitis B and C non-reactive. Thus, his findings were attributed to an active hepatitis A viral infection. He was treated conservatively with intravenous fluids and pain control. On discharge the patient remained afebrile, abdominal pain had resolved and liver function tests had normalized. DISCUSSION: Acute Hepatitis A with gallbladder involvement has been described in approximately 50 to 98% of adults. Although the etiology remains unclear, the invasion of the gallbladder by HAV and cell-mediated immunologic response have been proposed in the pathogenesis of HAV induced cholecystitis. The treatment is mainly conservative, as ACC due to HAV is transient and improves with resolution of viremia. Thus, patients do not require surgical interventions, unless they develop severe complications from ACC including gangrene and empyema. Our case demonstrates the importance of having a high clinical suspicion for HAV, especially in patients with known risk factors. Physicians should be cognizant of Hepatitis A and its rare extra hepatic manifestation, such as acalculous cholecystitis in order to avoid unnecessary surgical interventions.

Clinical study of real-time shear wave elastography for diagnosis of severity of acute cholecystitis

Objective: To assess the clinical value of real-time shear wave elastography (SWE) in distinguishing between mild and severe cholecystitis. Methods: A total of 176 patients with cholecystitis who meet the criteria of Tokyo Guideline in Wuxi People's Hospital of Nanjing Medical University from January 2017 to March 2018 were recruited, 95 male, 81 female, age range of 23-88 years, average age (48±16)years, and divided into severe (91 cases) and mild (85 cases) groups according to disease severity. All patients underwent routine ultrasound and SWE examination to assess gallbladder morphology, hepatic flow signals and liver cirrhosis adjacent to the gallbladder. Two sonographers with different diagnostic experience independently reviewed ultrasound images alone and in combination with SWE, respectively, and compared the diagnostic consistency of two sonographers in assessing severe cholecystitis. Results: The SWE value of liver in the severe group of cholecystitis was significantly higher than that of mild group (t=10.34, P=0.01). The area under the ROC curve of SWE value for diagnosing severe cholecystitis was 0.809 with the optimal cut-off value of 7.2 kPa. The sensitivity, specificity was 78.0% and 83.5%, respectively. In distinguishing between mild and severe cholecystitis, the diagnostic sensitivity (84.6%, 95.6%) was high and the specificity (49.4%, 35.3%) was low in diagnosing gallbladder edema and sludge.The diagnostic sensitivity (14.3%, 26.4%) was low and the specificity (100%, 95.3%) was high in diagnosing pericholecystic fluid and blood flow signal of the gallbladder wall.Two sonographers reviewed ultrasound images independently for diagnosing severe cholecystitis in good agreement (κ =0.75). Combining SWE to conventional ultrasound, the diagnostic consistency of the two sonographers in diagnosing server cholecystitis was excellent (κ=0.86), and the difference was statistically significant (P=0.02), the diagnostic efficacy of which was higher than that of conventional ultrasound alone. Conclusions: Compared with conventional ultrasound alone, combining with SWE can improve the diagnostic efficacy of distinguishing between mild and severe cholecystitis, and the clinical experience of sonographers has less influence on the diagnostic accuracy.

Complicated Case of Acute Fatty Liver of Pregnancy Without Deadly Outcome: Case Report

Background: Acute fatty liver of pregnancy (AFLP) is a rare disorder during pregnancy which is associated with microvesicular fatty infiltration of hepatocytes. We present a patient who was admitted with acute fatty liver of pregnancy. Case: 27-year old female gravida1, para 0 with a past medical history of gestational hypertension presented at her 32 weeks of gestation with uncontrolled hypertension; which evolved to preeclampsia. The patient was complaining of right upper quadrant pain and headache and had moderate tenderness in the right upper quadrant. Initially she received hydralazine, magnesium sulfate and betamethasone. Emergency cesarean section was done for fetal distress and severe preeclampsia. Her presentation was complicated with seizure requiring intubation. Initial labs showed: Na 129 ((mEq/L) K 6.3 (mEq/L) CO2 18 ((mEq/L) Creatinine 2.7 MG/DL) Magnesium 7.7 (mEq/L) phosphorus 7.9 (MG/DL) AST 3323 (U/L) ALT 2618 (U/L) WBC 24.5 (x109/L) hemoglobin 7.4 (MG/DL) platelets 70 (x109/L) INR 1.40 D Dimer 8418 (NG/ML) Fibrinogen 41(MG/DL) Uric acid 11.5 MG/DL). Patient AFLP was complicated by disseminated intravascular coagulation, intra-abdominal and intrahepatic/subscapular liver hematoma and hemoperitonium requiring emergent and laparotomy. She received multiple transfusions of packed red blood cells, fresh frozen plasma and cryoprecipitates. Head CT showed scattered parenchymal hemorrhage with significant intraventricular extension and development of obstructive hydrocephalus. She had emergent ventriculostomy placement followed by decompression craniotomy with bone flap removal.She had acute kidney injury requiring renal replacement therapy. Her protracted course ended up with discharged to a rehab facility after about 2 months of hospitalization. Later her neurological exam improved significantly. During rehabilitation, patient was able to practice with the treadmill, but she continued to have muscle stiffness. Discussion: AFLP is considered as an autosomal recessive genetic disorder. and considered as a diagnosis of exclusion.Labratory data such as Uric acid, ammonia and glocuse might assist with establishing the diagnosis.. About half of the patinets have PE/HELLP syndrome and this makes the initial diagnosis challenging. AFLP carries high mortality rate wich prompt multidisciplinary involvement is required to mange this condition in collaborative fashion to prevent fatal outcomes.2391_A Figure 1. CT head-scattered parenchymal hemorrhage within the right basal ganglia as well as corpus callosum, as described above, with significant intraventricular extension and development of obstructive hydrocephalus.2391_B Figure 2. CT abdomen- moderate ascites/hemoperitoneum. The heterogeneous density lateral to the liver is likely evolving hemorrhage.2391_C Figure 3. US of the liver showed small to moderate fluid lateral to the liver. Edematous and thick gallbladder wall.

An Unusual Case of Hepatitis Associated With Early Disseminated Lyme Disease

Lyme disease is a tick borne infection caused by Borrelia burgdorferi, a spirochete. Abnormal liver function tests have been occasionally associated with Lyme disease, but a case of hepatitis directly related to the infection has rarely been described in the literature. We present a case of a 28-year-old male who presented with one-week history of subjective fever, chills associated with progressive weakness, headache, nausea and vomiting. Physical examination showed scleral icterus and hepatomegaly. Laboratory studies were significant for thrombocytopenia 106, elevated liver function tests (LFT) with Alkaline phosphatase (ALP) 343, aspartate aminotransferase (AST) 160, alanine aminotransferase (ALT) 182, Total Bilirubin 5.06. Ultrasound of right upper quadrant showed enlarged porta-hepatic lymph node measuring 1.4 cm. CT abdomen showed mild hepatosplenomegaly with borderline sized retroperitoneal nodes, unremarkable pancreas and gall bladder sludge. Gastroenterology was consulted. Workup was negative for all infectious and immune causes of hepatitis, Human Immunodeficiency virus, Cytomegalovirus, Epstein-Barr virus, Babesia, Anaplasma and Erhlichia. Magnetic resonance cholangiopancreatography showed gallbladder edema with mild pericholecystic edema and trace amount of free fluid along the inferior liver edge with no gallstones ad intra or extra duct dilation. LFTs continued to trend up with Total Bilirubin 6.9, direct bilirubin 5.0, ALP 566, AST 368 and ALT 329. Patient continued to have worsening headache so CT head was done which was normal. Lumbar puncture was remarkable for elevated opening pressure of 42 cm, lymphocytic pleocytosis with Glucose 59, Protein 86. Serum Lyme immunoblot was positive with 2/3 bands so patient was started on Ceftriaxone and Doxycycline pending Cerebrospinal fluid analysis which was later negative for Cryptococcal antigen, bacterial or viral serology including Lyme. LFTs trended down significantly with Total Bilirubin 2.2, Direct Bilirubin 1.4, ALP 488, AST 81, and ALT 215. Ceftriaxone was discontinued and patient was discharged with Doxycycline for total of 14 days. Patient presented with obstructive jaundice and all autoimmune and infectious causes of hepatitis were ruled out. Following the diagnosis of Lyme disease, antibiotics were started and patient showed clinical improvement along with significant improvement in LFTs which raises high suspicion of hepatitis associated with Lyme disease as seen in our patient.

Study of hepatic dysfunction of dengue fever in children

Background: Dengue is a major international health concern that is prevalent in tropical and sub-tropical countries. It is estimated that worldwide nearly 2.5 billion people continue to live at risk of contracting the infection while 50 million cases and 24,000 deaths tend to occur in 100 endemic countries. Hepatic dysfunction is common in dengue fever and the degree of liver dysfunction in children varies from mild injury with to severe injury.Methods: Prospective and descriptive study was conducted on all the laboratory confirmed cases of dengue fever in children admitted at SIMS and RC over a period of 1 year from Dec 2015 to Nov 2016 both clinically and biochemically.Results: This study reveals, the prevalence of hepatic dysfunction in 30.6% (174/568) of the cases. Among the gender and age, majority of the hepatic dysfunction were seen in males 55.7% (97/174) and in the age group of 10-18 years 44.2% (77/174). Based on the severity, majority of hepatic dysfunction was seen in severe dengue cases 59.2% (103/174). Among clinical findings, most common symptom was jaundice 27.5% (48/174) and commonest sign was hepatomegaly 39.6% (69/174). The commonest liver function test altered was AST level in 45.4% (79/174) of the cases. Commonest abdominal USG finding was gall bladder edema in 90.8% (156/174) of the cases. The mortality was nil in this study.Conclusions: This study concludes prevalence of hepatic dysfunction was seen 30.6%, most of them seen in severe dengue 59.2% of the cases suggesting any febrile child with hepatic dysfunction, dengue infection should be suspected.

Study of nutritional status, comorbidities and other risk factors associated with dengue fever: data from a tertiary hospital in North India

Background: Dengue is a major health problem in India. The understanding of the factors which predispose to the infection and which are involved in its progression is fundamental for improved clinical outcomes. This study was initiated with the aim of identifying the patient population at risk and comorbidities involved in the development of complications.Methods: This was an observational and case control study in which 130 cases and controls taken from the healthy population were evaluated with respect to data regarding demographics, complications and co morbid metabolic diseases.Results: There was a predominance of males in cases as compared to controls especially between ages of 21-30 years . There was a significantly higher rate of comorbidities in cases as compared to controls and constituted 62.3% of the total cases. Obese /overweight cases were 60.8 %, fatty liver -30.76%, diabetics- 15.4 %, hypertensives 15.4%, cases of hypothyroidism 2.3 %, renal diseases 5.38% and ischemic heart disease 6.92%, 18.50% cases developed complications and severe disease (SD). There was a significant association of pleural effusion/ascites and gall bladder edema with SD. Association of comorbidities with SD was however not significant. Such cases tended to develop complications like heart failure, angina, renal failure and multiorgan failure and were difficult to treat. 5 (3.84%) patients died. 4 had associated comorbidities.Conclusions: Comorbidities like obesity predispose to dengue infection and are liable to cause serious complications knowledge of which can prompt early clinical intervention and reduction of mortality.