Elevated Alkaline Phosphatase Research Articles

Case Report: Case report: An unusual presentation of granulomatosis with polyangiitis

Aim: We are reporting a case of an unusual presentation of granulomatosis with polyangiitis (GPA) with liver involvement. Case presentation: A 45-year-old male patient presented with erythematous plaques on the face and bilateral nasal obstruction. On physical examination, the patient had a ring-shaped squamous plaque on the face. The laboratory findings revealed an accelerated erythrocyte sedimentation rate at 100 mm/h, an elevated C-reactive protein at 66 mg/L, hyper gamma globulinemia 16 g/L and an elevated alkaline phosphatase (twice the upper normal limit). The craniofacial and thoracoabdominal computed tomography (CT) -scans showed ethmoid and maxillary sinusitis, low facial bone density, multiple mediastinal and hilar lymphadenopathy, diffuse small pulmonary nodules, and hepatomegaly. A cutaneous lesion biopsy, the nasal mucosa, and the liver showed a chronic inflammatory granulomatosis process with necrosis. Serum anti-neutrophil cytoplasmic antibody (ANCA) against PR3 was positive. The clinical, biological, radiological, and histological findings substantiated the diagnosis of GPA. The patient received systemic steroids combined with cyclophosphamide pulses on days 1, 14 and 28 and then he was lost to follow-up. Two-years later, he presented with a cardiac failure and skin ulcer in the right lower limb. A nasal endoscopic exam showed nasal septum cartilage perforation with resorption of the middle and inferior nasal concha. Two weeks later, he developed a diffuse alveolar hemorrhage and was therefore transferred to the intensive care unit but died of respiratory failure 3 days later. Conclusion: Clinicians should be aware of GPA atypical clinical manifestations.

Clinicopathologic characteristics of liver inflammation and fibrosis in 310 patients with chronic hepatitis B.

Long-term hepatitis B virus (HBV) infection can cause recurrent inflammation in the liver, and then develop into liver fibrosis, cirrhosis, and liver cancer. The hepatic pathological change is one of the important criteria for guiding antiviral therapy in patients with chronic hepatitis B (CHB). Due to the limitations of liver biopsy, it is necessary to find valuable non-invasive indicators to evaluate the hepatic pathological changes in CHB patients and guide the antiviral therapy. This study aims to analyze the clinical characteristics of different pathological changes in CHB patients, and to explore the factors influnencing the degree of liver inflammation and fibrosis in CHB patients with normal alanine aminotransferase (ALT). This retrospective study was conducted on 310 CHB patients. Liver biopsy was performed in all these patients. The clinical data of the patients were collected. The liver biopsy pathological results were used as the gold standard to analyze the relationship between clinical indicators and liver pathological changes. Then CHB patients with normal ALT were screened, and the independent factors influencing the degree of liver inflammation and fibrosis were explored. Among the 310 patients with CHB, there were 249 (80.3%) patients with significant liver inflammation [liver inflammation grade (G) ≥2] and 119 (38.4%) patients with significant liver fibrosis [liver fibrosis stage (S) ≥2]. The results of univariate analysis of total samples showed that the ALT, γ-glutamyl transferase, alkaline phosphatase, and HBV DNA were related to the significant liver pathological changes. Among the 132 CHB patients with normal ALT, the patients with liver pathology G/S≥2, G≥2, and S≥2 were 80.3% (106/132), 68.2% (90/132), and 43.2% (57/132), respectively. The results showed that the independent influencing factor of significant liver inflammation was HBV DNA>2 000 U/mL (OR=3.592, 95% CI 1.534 to 8.409), and the independent influencing factors of significant liver fibrosis were elevated alkaline phosphatase level (OR=1.022, 95% CI 1.002 to 1.043), decreased platelet count (OR=0.990, 95% CI 0.982 to 0.998), and positive in hepatitis B e antigen (HBeAg) (OR=14.845, 95% CI 4.898 to 44.995). According to the multivariate analysis, a diagnostic model for significant liver fibrosis in CHB patients with normal ALT was established, and the area under the receiver operating characteristic curve was 0.844 (95% CI 0.779 to 0.910). The liver pathological changes should be evaluated in combination with different clinical indicators. A considerable number of CHB patients with normal ALT still have significant liver pathological changes, which need to be identified and treated with antiviral therapy in time. Among them, HBV DNA>2 000 U/mL suggests the significant liver inflammation, and the diagnostic model for significant liver fibrosis based on alkaline phosphatase, platelet count, and HBeAg can help to evaluate the degree of liver fibrosis.

Dietary antioxidants and liver enzymes in Rafsanjan, a Region in Southeast Iran

Oxidative stress has been considered the main contributor to liver injury. Dietary antioxidants would be expected to improve liver function. The hepatoprotective effects of antioxidants are controversial. In the present study, the associations of some dietary antioxidants and the levels of serum liver enzymes were examined. This cross-sectional study was conducted using the Rafsanjan Cohort Study (RCS) data as a population-based prospective cohort which is a part of the Prospective Epidemiological Research Studies in IrAN (PERSIAN). A total of 9942 participants aged 35–70 years old were included in this study. Among this population, 4631 (46.59%) were male, and 5311 (53.42%) were female. Dietary intakes were collected by a validated food frequency questionnaire (FFQ) with 128 items. Aspartate transaminase (AST), Alanine transaminase (ALT), γ-glutamyl transferase (GGT), and Alkaline phosphatase (ALP) were measured by a biotecnica analyzer. Dichotomous logistics regression models were used to investigate the association between the elevated liver enzymes and intake of dietary antioxidants using crude and adjusted models. In the adjusted model, in subjects with higher consumption of Se, Vit A, Vit E, β-carotene, α-carotene, and β-cryptoxanthin, the odds ratios of elevated ALP were decreased compared to the reference group (ORs 0.79 (0.64–0.96), 0.80 (0.66–0.98), 0.73 (0.60–0.89), 0.79 (0.64–0.96), 0.78 (0.64–0.95), 0.80 (0.66–0.98), and 0.79 (0.64–0.98), respectively). Subjects with higher consumption of Se, Vit A, Vit E, and provitamin A carotenoids (β-carotene, α-carotene, β-cryptoxanthin) showed decreased odds of elevated ALP. These findings support the hypothesis that Se, Vit A, Vit E, and provitamin A carotenoids may be associated with improvements in ALP and act as suppressors against the development of liver injury.

Distribution of per- and polyfluoroalkyl substances in blood, serum, and urine of patients with liver cancer and associations with liver function biomarkers

Studies have shown that per- and polyfluoroalkyl substances (PFASs) may be hepatotoxic in animals or humans. However, data on clinical epidemiology are very limited. In this study, 21 PFASs were determined in patients with liver diseases, with the highest median concentrations detected in the serum sample (26.7 ng/mL), followed by blood (10.7 ng/mL) and urine (5.02 ng/mL). Higher total PFAS concentrations were found in hepatocellular carcinoma (HCC) patients compared to non-HCC patients, with significant discrepancies in serum and blood samples. Besides, significant correlations were also found among PFAS concentrations and age, gender, body mass index (BMI), and liver function biomarkers levels. For example, PFAS concentrations are significantly higher in males than in females; Several serum PFASs concentrations increase with age and BMI, while the serum perfluorohexane sulfonic acid (PFHxS) concentrations are negatively correlated with age. In addition, multiple regression models adjusted for age, gender and BMI found that increased serum perfluorobutane sulfonic acid (PFBS), perfluoroheptane sulfonic acid (PFHpS) and perfluorohexylphosphonic acid (PFHxPA) conentrations are correlated with elevated alkaline phosphatase (ALP), aspartate aminotransferase (AST), and alpha-fetoprotein (AFP) (p < 0.05). Our results provide epidemiological support for the future study on the potential clinical hepatotoxicity of PFAS.

Synthesis, molecular docking, and protective effect of novel thiohydantoin derivative: (Z)-5-(pyridin-2-ylmethylene)-2-thioxothiazolidin-4-one in a diethynitrosamine model of hepatotoxicity

BackgroundDiethyl nitrosamine (DEN) consumption was well documented to cause liver cell damage, compensatory proliferation, and inflammation, so this study aimed to examine the hepatoprotective effects of (Z)-5-(pyridin-2-ylmethylene)-2-thioxothiazolidin-4-one (Z5–2T) on diethyl nitrosamine (DEN) induced liver damage in a rat model. MethodsThirty male wistar rats were divided into three groups, each with ten rats, as the following, Group 1: Vehicle (normal saline), group 2: DEN control, 200 mg/kg single dose injection intraperitonially, group 3: were given 50 mg/kg by oral feeding of (Z5–2T). Five rats from each group were sacrificed in the second week of the experiment, and the other half were sacrificed in the sixth week. Resultsinjection of 200 mg/kg of DEN to rats resulted in elevation of liver function enzymes Total Bilirubin (8.02 ± 0.1 mg/dL), direct Bilirubin (8.22 ± 0.2 mg/dL), indirect Bilirubin (0.03 ± 0.03 mg/dL), aspartate Aminotransferase (303 ± 1.2 U/L), alanine Aminotransferase (287 ± 0.9 U/L) and alkaline Phosphatase (390 ± 0.6 U/L) indicating liver damage, along with elevation in the TNF-α and IL-6. The results of both LFTs and ELISA in the treatment group showed improvements and exhibited decline in the levels of the markers. Histopathological examination showed fibrosis, necrosis, and infiltration of inflammatory cells in DEN group, with less intensity in the treatment group. Immunohistochemistry staining reveled strong positive staining of both HSA and ki-67 antibodies in the DEN group, with much less intensity in the treatment group. The correct absorption and binding between the drug and the receptor were evaluated through computerized molecular docking by using AutoDock program. (Z5–2T) had remarkable interaction with TNF-α (PDB ID:1TNF) and IL-6 (PDB ID: 1IL6), binding site energy -6.5 and -6.0 (kcal/mol), respectively. Conclusionhepatoprotective effect of the (Z5–2T) against DEN-induced hepatocellular damage and cancer in experimental rats was accomplished.

Schnitzler Syndrome Presenting as a Fever of Unknown Origin with Elevated Alkaline Phosphatase Levels.

Schnitzler syndrome (SchS) is a rare, acquired, autoinflammatory disease that is sometimes associated with a fever of unknown origin (FUO). Elevated alkaline phosphatase (ALP) stemming from abnormal bone remodeling is a characteristic laboratory finding of SchS and is included in the diagnostic criteria. However, its utility as a clue to the diagnosis of SchS has been under-emphasized. We herein report a case of SchS presenting with a FUO and highly elevated ALP concentration, which led to repeated, unnecessary liver biopsies.

Liver injury at admission and outcomes in patients with COVID-19 disease: a prospective cohort study.

This is a single-center prospective observational study. All consecutive patients with COVID-19 admitted during the months of May to August 2021 were included in the study. Liver injury was defined as at least 2 times elevation of aspartate transaminase, alanine transaminase, alkaline phosphatase, and bilirubin above the upper limits on normal. The predictive efficacy of liver injury was measured as its effects on outcome variables, that is duration of hospital stay, requirement of ICU admission, mechanical ventilation, and mortality. Presence of liver injury compared with existing biomarkers markers of severe disease, that is lactate dehydrogenase, D-dimer, and C-reactive protein. A total of 245 consecutive adult patients with COVID-19 infection were included in the study. Liver injury was present in 102 (41.63%) of patients. There was a significant association between the presence of liver injury and duration of hospital stay (10.74 vs. 8.9 days; P=0.013), the requirement of ICU admission (12.7 vs. 10.2%; P=0.018), mechanical ventilation (10.6% vs. 6.5%; P=0.003), and mortality (13.1% vs. 6.1%; P<0.001). Liver injury was significantly associated (P<0.001) with the corresponding elevation of serum biomarkers of severity. The presence of liver injury in patients with COVID-19 infection at the time of hospital admission is the independent predictor of poor outcomes and can also be used as the marker of disease severity.

Primary sclerosing cholangitis with partial steroid responsiveness: a case report.

A 69-year-old woman suspected to have IgG4-related sclerosing cholangitis causing bile duct stenosis was transferred from another hospital after diarrhea, eosinophilia, and eosinophilic infiltration were detected and prednisolone was prescribed. Additional biliary imaging suggested primary sclerosing cholangitis, but the IgG4 level and inferior bile duct stenosis were alleviated by steroid therapy, suggesting IgG4-related sclerosing cholangitis. Therefore, prednisolone was continued. Bile duct biopsy findings suggesting adenocarcinoma led to a diagnosis of pancreatoduodenectomy. The latter specimen only displayed evidence of primary sclerosing cholangitis, and prednisolone was discontinued. Intractable cholangitis necessitated left hepatectomy, after which serum alkaline phosphatase levels increased and eosinophilic colitis recurred. The reintroduction of prednisolone effectively managed the diarrhea but only temporarily reversed the alkaline phosphatase elevation. When histologic sections from resection specimens were compared, the hepatectomy specimen exhibited greater eosinophil infiltration than the earlier pancreatoduodenectomy specimen, suggesting eosinophilic cholangiopathy superimposed on primary sclerosing cholangitis.

Formulation and validation of a baseline prognostic score for osteosarcoma treated uniformly with a non-high dose methotrexate-based protocol from a low middle income healthcare setting: a single centre analysis of 594 patients.

The outcomes of osteosarcoma in low middle income countries (LMICs) are different due to patients presenting in advanced stages, resource constraints and the use of non-high-dose-methotrexate (HDMTX)-based regimens. This study derived and validated a prognostic score for osteosarcoma that integrates biologic and social factors and is tailored for patients from an LMIC setting using a non-HDMTX-based protocol. A retrospective study including osteosarcoma patients enrolled for treatment at a single tertiary care centre in India between 2003-19 was conducted. Baseline biologic and social characteristics were extracted from medical records and survival outcomes were noted. The cohort was randomised into a derivation and validation cohort. Multivariable Cox regression was used to identify baseline characteristics that were independently prognostic for survival outcomes in the derivation cohort. A score was derived from the prognostic factors identified in the derivation cohort and further validated in the validation cohort with estimation of its predictive ability. 594 patients with osteosarcoma were eligible for inclusion in the study. Around one-third of the cohort had metastatic disease with 59% of the patients residing in rural areas. The presence of metastases at baseline (HR 3.39; p<0.001; score=3), elevated serum alkaline phosphatase (SAP) >450 IU/L (HR 1.57; p=0.001; score=1) and baseline tumour size > 10 cm (HR 1.68; p<0.001; score=1) were identified to be independent factors predicting inferior event free survival (EFS) and were included in development of the prognostic score. Patients were categorized as low risk (score 0), intermediate risk (score 1-3) and high risk (4-5). Harrell's c-indices for the score were 0.682, 0.608 and 0.657 respectively for EFS in the derivation, validation and whole cohort respectively. The timed AUC of ROC was 0.67 for predicting 18-month EFS in the derivation, validation and whole cohorts while that for 36-month EFS were 0.68, 0.66 and 0.68 respectively. The study describes the outcomes among osteosarcoma patients from an LMIC treated uniformly with a non-HDMTX-based protocol. Tumor size, baseline metastases and SAP were prognostic factors used to derive a score with good predictive value for survival outcomes. Social factors did not emerge as determinants of survival.

Effects of burosumab treatment on mineral metabolism in children and adolescents with X-linked hypophosphatemia.

Burosumab has been approved for the treatment of children and adults with X-linked hypophosphatemia (XLH). Real-world data and evidence for its efficacy in adolescents is lacking. To assess the effects of 12 months burosumab treatment on mineral metabolism in children (aged < 12 years) and adolescents (aged 12-18 years) with XLH. Prospective national registry. Hospital clinics. 93 XLH patients (65 children, 28 adolescents). Z-scores for serum phosphate, alkaline phosphatase (ALP), and renal tubular reabsorption of phosphate per glomerular filtration rate (TmP/GFR) at 12 months. At baseline, patients showed hypophosphatemia (-4.4 SD), reduced TmP/GFR (-6.5 SD) and elevated ALP (2.7 SD, each p < 0.001 versus healthy children) irrespective of age, suggesting active rickets despite prior therapy with oral phosphate and active vitamin D in 88% of patients. Burosumab treatment resulted in comparable increases in serum phosphate and TmP/GFR in children and adolescents with XLH, and a steady decline in serum ALP (each p < 0.001 versus baseline). At 12 months, serum phosphate, TmP/GFR, and ALP levels were within the age-related normal range in approximately 42%, 27% and 80% of patients in both groups, respectively, with a lower, weight-based final burosumab dose in adolescents compared to children (0.72 versus 1.06 mg/kg, p < 0.01). In this real-world setting, 12 months of burosumab treatment was equally effective in normalizing serum ALP in adolescents and children, despite persistent mild hypophosphatemia in half of patients, suggesting that complete normalization of serum phosphate is not mandatory for substantial improvement of rickets in these patients. Adolescents appear to require lower weight-based burosumab dosage than children.

POEMS syndrome associated with vitiligo (P13-8.007)

<h3>Objective:</h3> To report a case of POEMS syndrome with vitiligo. This is the second case to be reported and the first in an Afro-American patient. <h3>Background:</h3> POEMS syndrome is a rare plasma-cell disorder with multisystem involvement, characterized by the acronym composing its name: Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal protein (M-protein), and Skin changes. Major criteria include mandatory polyneuropathy and monoclonal plasma cell proliferative disorder in addition to Castleman’s disease, sclerotic bone lesions, or elevated vascular endothelial growth factor (VEGF). Minor criteria, still helpful for diagnosis, include organomegaly, endocrinopathy, papilledema, thrombosis, and skin changes, the most common being hyperpigmentation. <h3>Design/Methods:</h3> Case Presentation <h3>Results:</h3> A 50-year-old Afro-American male presented with 3 years of ascending stocking-glove pattern numbness and skin discoloration in his feet. Other positive history included anhidrosis, heat intolerance and erectile dysfunction suggestive of dysautonomia. Medical history included hypoparathyroidism and idiopathic cirrhosis. He did not have history of alcohol overuse, diabetes, or glucose intolerance. Examination revealed confluent hypopigmented macules in feet, vibratory sensation impairments up to knees, absent temperature sensation in feet, and abnormal Romberg test and tandem gait. Remainder of the neurological examination was normal. Laboratory tests were significant for elevated free kappa and lambda light chains, plasma VEGF levels twice over normal range, and an IgA monoclonal band on serum protein electrophoresis. Other relevant laboratory findings included PTH-independent hypercalcemia and alkaline phosphatase elevation. Radiographs of hands, elbows, shoulders, and knees disclosed non-sclerotic lytic lesions. Nerve conduction studies were consistent with a sensorimotor axonal polyneuropathy. The patient met diagnostic criteria for POEMS syndrome. Autologous stem cell transplantation was recommended but the patient declined. His vitiligo, neuropathy, and monoclonal gammopathy remain stable under surveillance at 4 years without pharmacotherapy. <h3>Conclusions:</h3> POEMS syndrome should be suspected in any patient with new onset of vitiligo in the presence of an underlying polyneuropathy and a monoclonal plasma cell proliferative disorder. <b>Disclosure:</b> Dr. Landman has nothing to disclose. Dr. Escobar-Montealegre has nothing to disclose. Dr. Singh has nothing to disclose. Dr. Morales has nothing to disclose. Dr. Rossi has nothing to disclose.

Case Report: An unusual presentation of granulomatosis with polyangiitis

Aim: We are reporting a case of an unusual presentation of granulomatosis with polyangiitis (GPA) with liver involvement. Case presentation: A 45-year-old male patient presented with erythematous plaques on the face and bilateral nasal obstruction. On physical examination, the patient had a ring-shaped squamous plaque on the face. The laboratory findings revealed an accelerated erythrocyte sedimentation rate at 100 mm/h, an elevated C-reactive protein at 66 mg/L, hyper gamma globulinemia 16 g/L and an elevated alkaline phosphatase (twice the upper normal limit). The craniofacial and thoracoabdominal computed tomography (CT) -scans showed ethmoid and maxillary sinusitis, low facial bone density, multiple mediastinal and hilar lymphadenopathy, diffuse small pulmonary nodules, and hepatomegaly. A cutaneous lesion biopsy, the nasal mucosa, and the liver showed a chronic inflammatory granulomatosis process with necrosis. Serum anti-neutrophil cytoplasmic antibody (ANCA) against PR3 was positive. The clinical, biological, radiological, and histological findings substantiated the diagnosis of GPA. The patient received systemic steroids combined with cyclophosphamide pulses on days 1, 14 and 28 and then he was lost to follow-up. Two-years later, he presented with a cardiac failure and skin ulcer in the right lower limb. A nasal endoscopic exam showed nasal septum cartilage perforation with resorption of the middle and inferior nasal concha. Two weeks later, he developed a diffuse alveolar hemorrhage and was therefore transferred to the intensive care unit but died of respiratory failure 3 days later. Conclusion: Clinicians should be aware of GPA atypical clinical manifestations.

COVID-19 related biliary injury: A review of recent literature

Since its emergence in 2019, it has become apparent that coronavirus 2019 (COVID-19) infection can result in multi systemic involvement. In addition to pulmonary symptoms, hepatobiliary involvement has been widely reported. Extent of hepatic involvement ranges from minor elevation in liver function tests (LFTs) to significant hepatocellular or cholestatic injury. In majority of cases, resolution of hepatic injury or improvement in LFTs is noted as patients recover from COVID-19 infection. However, severe biliary tract injury progressing to liver failure has been reported in patients requiring prolonged intensive care unit stay or mechanical ventilation. Due to the timing of its presentation, this form of progressive cholestatic injury has been referred to as COVID-19 cholangiopathy or post-COVID-19 cholangiopathy, and can result in devastating consequences for patients. COVID-19 cholangiopathy is recognized by dramatic elevation in serum alkaline phosphatase and bilirubin and radiologic evidence of bile duct injury. Cholangiopathy in COVID-19 occurs weeks to months after the initial infection and during the recovery phase. Imaging findings and pathology often resemble bile duct injury associated with primary or secondary sclerosing cholangitis. Etiology of COVID-19 cholangiopathy is unclear. Several mechanisms have been proposed, including direct cholangiocyte injury, vascular compromise, and cytokine release syndromes. This review summarizes existing data on COVID-19 cholangiopathy, including reported cases in the literature, proposed pathophysiology, diagnostic testing, and long-term implications.

Heroin-induced osteoporosis presented with bilateral femoral neck insufficiency fractures in a male adult: a case report

BackgroundOsteoporosis has been associated with several disorders; however, there have been only a limited number of reports on heroin-induced osteoporosis. We report a rare case presented with bilateral femoral neck insufficiency fractures without trauma history, caused by heroin-induced osteoporosis. We collect sufficient clinical data and further shed light on the potential mechanism of how heroin affects bone formation and decreases bone density.Case presentationA 55-year-old male patient with normal body mass index (BMI) suffered from bilateral hips pain gradually without trauma history. He had intravenous heroin addiction for more than 30 years. Radiography revealed bilateral femoral neck insufficiency fractures. Laboratory tests showed elevated alkaline phosphatase levels (365 U/L) and decreased inorganic phosphate (1.7 mg/dL), calcium (8.3 mg/dL), 25-(OH)D3 (20.3 ng/ml) and testosterone levels (2.12 ng/ml). Magnetic resonance imaging (MRI) revealed increased signals on STIR images over the sacral ala and bilateral proximal femur, and multiple band-like lesions at the vertebrae of the thoracic and lumbar spine. Bone densitometry revealed osteoporosis with a T score of minus 4.0. The screen for urine morphine was positive (> 1000 ng/ml). Through assessment of the patient, the diagnosis was insufficiency fractures of bilateral femoral neck caused by opioid-induced osteoporosis. After hemiarthroplasty, regular medication with vitamin D3 and calcium, and detoxification treatment, and the patient recovered well after 6 months of follow-up.ConclusionThe aim of this report is to highlight the laboratory and radiology findings in a case of osteoporosis caused by opioid addiction and discuss the potential pathway by which osteoporosis is induced by opioids. When an unusual osteoporosis presents with insufficiency fractures, heroin-induced osteoporosis should be considered.

Liver manifestations of tick-borne diseases.

Liver manifestations of tick-borne diseases.

Hepatic Amyloidosis With Multiorgan Involvement

Amyloidosis is a diverse entity that poses both diagnostic and treatment challenges. Whether systemic or local, amyloidosis has varied manifestations including occasional hepatic involvement. Hepatic amyloidosis, although rare, should be on the differential for those with unexplained hepatomegaly, cholestasis, alkaline phosphatase elevations, other associated organomegaly, and those with certain epidemiologic risks. In this study, we report a case of a man with systemic amyloid light chain amyloidosis with multiorgan involvement, acute liver injury, cholestasis, nephrotic syndrome, cardiomegaly, and bleeding diathesis.

Giant Liver Abscess with Atypical Clinical Presentation: Case Report

Background. Amebiasis is caused by the protozoan Entamoeba histolytica. This parasite exists in 2 stages: a cyst, which is the infective form, and a trophozoite stage, which is the form that causes invasive disease. Globally, around 500 million people are infected annually. Clinical case. A 73-year-old female upon arrival at the emergency department with laboratories without alterations. Relevant ultrasound reports chronic gallbladder lithiasis not exacerbated and significant gastric distension. A liver abscess is suspected, for which an assessment is requested by the interventional radiology service for percutaneous drainage, commenting that it is not a candidate because, due to ultrasonographic characteristics in the scan before the puncture, they suspect a hydatid cyst and the puncture site is proximal to the blood vessels. It is programming exploratory laparotomy with the following findings: enlarged liver, firm adhesions to the posterior wall of the stomach and the diaphragm, a hepatic abscess is drained, obtaining 2000 mL of thick purulent material, it is marsupialized and culture is taken with a negative report to bacterial development at 48 hours. Discussion. It is a 44-year-old male with intense abdominal pain in the right upper quadrant, generalized jaundice, tachycardia, and fever; the hepatic edge is palpated 5 cm below the costal margin, positive Murphy's sign. Laboratory studies: direct hyperbilirubinemia, elevation of alkaline phosphatase and transaminases, leukocytosis, a negative viral panel for hepatitis, and positive antibodies for Entamoeba histolytica. The abdominal computed tomography showed a hypodense lesion measuring 15 by 12.1 cm in the right hepatic lobe.

Clinical Images: Increased bone metabolism in secondary hyperparathyroidism.

The patient, a 47-year-old man, was diagnosed as having severe hyperparathyroidism secondary to end-stage kidney disease (ESKD), the underlying cause being leukocytoclastic vasculitis with IgA nephritis and minimal-change glomerulonephritis, which was confirmed by kidney biopsy in 2008. The patient had been receiving hemodialysis since 2014 and had a history of multiple fractures. His treatment included azathioprine, low-dose prednisolone, calcium carbonate, vitamin D, sevelamer, cinacalcet, torasemide, carvedilol, amlodipine, moxonidine, simvastatin, low molecular weight heparin, and erythropoietin. After a sudden transitory episode of vision loss with increased C-reactive protein (18.1 mg/liter) and response to glucocorticoids, 18F–positron emission tomography/computed tomography (18F-PET/CT) evaluation was performed to rule out systemic vasculitis. Ophthalmologic examination was negative for arteritic ischemic optic neuropathy, ophthalmoparesis, loss of visual field, and diplopia. Imaging with 18F-PET/CT revealed enhanced fluorodeoxyglucose uptake in the skeleton (A and B) and thickening of cortical bone such as in the femurs (C). Bone loss as osteolytic lesions in the calvaria, increased uptake in the setting of diffuse skull thickening with loss of distinction between the inner and outer table (D), and increased uptake in mandible bones (E) could be seen. There was no evidence for vasculitis. ESKD is associated with a complex remodeling of bone, summarized as renal osteopathy (1). This might include bone resorption, periosteal reaction, brown tumors, osteoporosis, osteosclerosis, osteomalacia, and soft tissue/vascular calcifications. Imaging may reveal any number of these conditions (2, 3). In our patient, 18F-PET/CT revealed osteolytic lesions, which were considered brown tumors and interpreted as osteitis fibrosa cystica. The patient was hypocalcemic (adjusted serum calcium 1.90 mmoles/liter), with elevated alkaline phosphatase (758 IU/liter) and massively elevated parathyroid hormone levels (1,872 pmoles/liter), indicating severe secondary hyperparathyroidism. These 18F-PET/CT images reflect the widespread, strongly induced metabolic activity of bone in secondary hyperparathyroidism during ESKD. Disclosure Form Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Multiple Bone Metastases as the Initial Presentation of Occult Breast Carcinoma in a Kidney Transplant Recipient

Introduction: Due to their immunosuppressive medication regimen, solid organ transplant recipients have an increased risk of developing cancer, which might jeopardize their survival. Specifically, cardiovascular disease and malignancy are the two leading causes of death in kidney transplant recipients. In solid organ recipients, cutaneous malignancies, lymphomas, and Kaposi’s sarcomas also appear to be the most prevalent cancer forms. Thus, carcinoma of unknown primary origin is a clinical entity that diagnosing requires a high level of suspicion and thorough reviewing of laboratory, radiological, and clinical findings. Further, susceptible patients, such as immunocompromised ones, should merit a careful analysis of findings and detailed analytic rationale. We, therefore, present the following case report demonstrating the importance of follow-up of specific suspicious serum markers in transplant patients. To our knowledge, this study is the first case to report an occult breast carcinoma as the initial presentation in a patient with a kidney transplant.Case Presentation: In the following case, the primary indication for malignancy was elevated alkaline phosphatase (ALP), a common finding in patients with chronic renal failure. Once noticed in a scheduled post-transplantation follow-up, further diagnostic tests, such as a broader serum panel, sternal puncture, and mammography, were ordered and returned normal. Subsequently, CT was ordered and revealed lytic and sclerotic bone changes. Afterward, serum tumor markers were ordered together with gynecological ultrasound and PET-CT. Finally, an iliac bone marrow biopsy confirmed a breast cancer diagnosis of unknown primary origin, causing the elevated ALP.Conclusions: This case report presents a uniquely difficult diagnostic challenge as an expected elevated value of ALP in a kidney transplant recipient was the only diagnostic clue for occult breast carcinoma. We discuss further the vigilance that physicians must exert when dealing with kidney transplant recipients and the implication of carcinoma of unknown primary in this population.

A pregnant with markedly elevated alkaline phosphatase: a case report

Alkaline Phosphatase (ALP) is produced from the liver, kidney, bone and placenta. During pregnancy, ALP may raise markedly with no clear reason. Here, we present a rare case of highly elevated ALP in a 21 years old pregnant woman during the third trimester who had no important past medical history. It was 2800 U/L. Bone, renal, or liver was all normal. Close monitoring of the fetus and his mother until birth was the way of treatment. We had seven weeks postpartum to decline in ALP concentration but did not return to the normal range. The placenta showed lesions of chronic villitis. The extreme incline in ALP during the gestational stages is riskier because the threat here is posed to 2 lives. In such conditions, constant monitoring of ALP in the maternal serum backed with necessary medication is required.