Viral Hepatitis Markers Research Articles

Improved ascertainment of modes of HIV transmission in Ukraine indicates importance of drug injecting and homosexual risk

BackgroundIt is important to understand how HIV infection is transmitted in the population in order to guide prevention activities and properly allocate limited resources. In Ukraine and other countries where injecting drug use and homosexuality are stigmatized, the information about mode of transmission in case registration systems is often biased.MethodsWe conducted a cross-sectional survey in a random sample of patients registered at HIV clinics in seven regions of Ukraine in 2013–2015. The survey assessed behavioral risk factors and serological markers of viral hepatitis B and C. We analyzed the discrepancies between the registered mode of transmission and the survey data, and evaluated trends over 3 years.ResultsOf 2285 participants, 1032 (45.2%) were females. The proportion of new HIV cases likely caused by injecting drug use based on the survey data was 59.7% compared to 33.2% in official reporting, and proportion of cases likely acquired through homosexual transmission was 3.8% compared to 2.8%. We found a significant decrease from 63.2 to 57.5% in the proportion of injecting drug use-related cases and a steep increase from 2.5 to 5.2% in homosexual transmission over 3 years.ConclusionsThe study confirmed the significant degree of misclassification of HIV mode of transmission among registered cases. The role of injecting drug use in HIV transmission is gradually decreasing, but remains high. The proportion of cases related to homosexual transmission is relatively modest, but is rapidly increasing, especially in younger men. Improvements in ascertaining the risk factor information are essential to monitor the epidemic and to guide programmatic response.

The impact of the infection caused by hepatitis B and C on the characteristics of hepatotoxic reactions in tuberculosis patients

The objective of the study: to identify the specific parameters of hepatotoxic reactions in tuberculosis patients depending on the presence of hepatitis B and C markers in the blood. Subjects and methods. The state of the hepatobiliary system was studied in 107 HIV-negative patients with newly diagnosed infiltrative pulmonary tuberculosis in the destructive phase. The main group included 52 people with positive results of the tests for markers of viral hepatitis B and C, the comparison group included 55 people with negative results. The groups were compatible in age, volume of the lung tissue lesions, and drug resistance profile. Results. Even before the start of anti-tuberculosis therapy, in the main group had elevated levels of cholinesterase and blood amylase, ultrasound examination detected hyperechoic liver parenchyma, enlarged right lobe of the liver, liver veins fibrosis, the enlarged diameter of the cystic duct and splenic vein, and splenomegaly (p <0.05), which was statistically significantly more frequent than in the comparison group. In the course of treatment, patients of both groups developed hepatotoxic reactions, however, in the main group they were more frequent versus the comparison group (88.4 and 21.8%, respectively, p <0.05), appeared earlier on average by 14 days and were accompanied by more pronounced clinical manifestations and abnormalities of biochemical parameters.

The Frequency of Hepatitis Virus Infection Markers Among Highly Qualified Sportsmen

Study Objective is to evaluate prevalence of hepatitis A, B, C, E, and TT virus infection markers in highly qualified sportsmen. Study Design: multicenter open single-site clinical study.Materials and Methods: 100 blood serum samples of sportsmen (game, complex coordination, technical, etc.) were studied. Biological material (blood serum) was obtained from 54 men and 46 women aged 16 to 45 years during an in-depth medical examination. All sportsmen filled out a questionnaire, including demographic data, description of the sport, information about infection risk factors, information about the presence of acute viral hepatitis and vaccination. Anti-HAV IgG, HBsAg, anti-HBcore, anti-HCV, anti-HEV IgG, anti-HEV IgM were determined in the blood serum by enzyme immunoassay; using polymerase chain reaction — DNA Anelloviridae (TTV, TTMDV, TTMV). Study Results: Anti-HAV IgG was detected in 57/66 (86,4%) sportsmen, women (91,2%) predominated, among them a third were engaged in synchronized swimming. 7/57 (12,3%) of the examined had indications of vaccination against hepatitis A. The frequency of anti-HEV IgG did not exceed 3% (2/66). anti-HEV IgM were not detected in any case. Also, none of the examined sportsmen in the blood serum was not determined HBsAg. However, anti-HBcore (marker of latent HBV infection) was detected in 13% (13/100) of the samples. The detection rate of anti-HCV was low, combined with the presence of anti-HBcore was 2% (2/100). In addition, DNA TTV, TTMDV and TTMV, respectively, were found in serum samples from 66/100 (86%), 79/100 (79%), 71/100 of sportsmen. Conclusion: The high frequency of hepatitis virus markers was found (HAV — 74,1%, TTV/TTMDV /TTMV — 71-86%), HBV — 13%, HEV — 3%, HCV — 2%). All patients denied a history of acute viral hepatitis. Vaccination against hepatitis A and B is a modern strategy that prevents infection and the development of acute viral hepatitis. Its mandatory holding should become part of the targeted preparation of sportsmen to achieve the highest sports results.

Modern Features of Hepatitis a Epidemic Process in Large City of European Russia

Purpose of the studywas to characterize modern features of hepatitis A epidemic process in large city of European Russia and optimization of epidemic surveillance of the infection.Materials and methods. Hepatitis A incidence data were analyzed in long-term period 1968–2017. Etiologic structure of acute viral hepatitis was identified by both incidence data and extended set of viral hepatitis markers in patients with jaundice (n = 144). Anti-HAV prevalence rate was studied in population of N. Novgorod by immuno-enzyme method in 2014 and 2017 (n = 1728, age: 1–60 years old).Results and discussion. Share of hepatitis A in etiology of acute viral hepatitis did not significantly change in 2007–2017, if compared to 1994–2006 (50,8 ± 9,2% and 56,1 ± 13,3% respectively, р > 0,05), but it varies greatly depending on the phase of epidemic process of the infection. Modern period is characterized by 9 times reduction of the incidence rate and extension of epidemic cycle up to 10 years. Age structure of morbidity in modern conditions is defined by age groups of children 3–14 years old. Seasonal variability of the incidence rate was reduced in non-epidemic phase of epidemic process and in age group of adults. Anti-HAV antibodies were detected in 30,9 ± 1,9% of the city population in 2014, and this rate was even lower in 2017 (24,8 ± 1,6%). This data indicates that non-epidemic phase seroprevalence in modern conditions has decreased when compared to former period (from 51,5 ± 1,9% in 1998, p < 0,001). These changes primarily affect group of adults 30–59 years old.Conclusion. Presented characteristics of hepatitis A epidemic process play crucial role in the risk assessment of hepatitis A in modern period and must be implemented as first step in optimization of epidemic surveillance of hepatitis A.

Vitamine D supply in girls of puberty age with autoimmune hepatitis

Vitamin D undergoes important biotransformation and inactivation in the liver. Because vitamin D is metabolized in the liver, abnormal vitamin D metabolism can be expected to be associated with chronic liver disease, including autoimmune hepatitis (AIH). The prevalence of vitamin D deficiency in puberty was the justification for the objective of the study– to determine the characteristics of vitamin D supply in girls of puberty age with AIH with autoimmune hepatitis during this period. Materials and methods. To solve this goal, a comprehensive clinical and paraclinical examination of 66 girls withAIH and 180 relatively healthy girls of the control group aged 12-17 years. The complex included clinical and anamnestic data, biochemical study of liver function, determination of serum autoantibodies and markers of viral hepatitis, the level of 25- (OH) D in blood serum, ultrasound and elastography of the hepatobiliary system organs, liver biopsy. Results. The mean level of vitamin 25 (OH) D in the serum of girls with AIH of pubertal age was 17.14 ± 1.06 vs. 23.27 ± 0.53 ng / ml in the control (p<0,01). In 66.67% of patients with AIH there was a deficiency of 25 (OH) D, in 22.73% – insufficiency, in 10.61% – the optimal level. The supply of vitamin D depended on the histological activity of AIG. Among girls with AIH and histological activity index> 9 points, the share of patients with vitamin D deficiency was 79.41% compared with 53.13% of cases among girls with AIH, where the histological activity index was <9 points (χ2=5.13; p<0,02). Conclusions. Cytolysis, cholestasis, mesenchymal-inflammatory syndrome, hepatocellular insufficiency in AIH in girls of puberty agedevelops against the background of reduced vitamin D supply, which depends on the histological activity of the disease.

Determination of potential biotin interference on accuracy of results of serologic assays for various viral hepatitis markers.

Biotin taken orally can interfere with some diagnostic immunoassays, including those for thyroid hormones, ferritin, and markers of infectious disease. Assays affected are ones that use streptavidin-biotin in their design. The goal of our study was to examine the effect of biotin concentrations of up to 1200 ng/mL on three serological assays performed on VITROS 3600 system, Immunoglobulin M (IgM) antibodies to hepatitis A virus (anti-HAV), total anti-HAV, and IgM antibodies to hepatitis B virus core antigen (anti-HBc), by spiking serum samples with variable amounts of biotin. No false-negative results were generated with either concentration of biotin for total anti-HAV (65/65). Likewise, biotin caused no false-positive IgM anti-HAV results (59/59) with either concentration of biotin; however, 6.7% false negativity was found for IgM anti-HAV when samples were spiked with 1200 ng/mL of biotin. Conversely, 100% false positivity (30/30) was produced by biotin interference in total anti-HAV negative specimens with both concentrations of biotin. False negativity rate was 87.5% in IgM anti-HBc positive samples when biotin levels were at 1200 ng/mL. These data show that individuals taking biotin-containing supplements may test false-positive in some serologic assays using streptavidin-biotin chemistries. Further studies are warranted to determine the extent of biotin interference resulting in false-positive and negative results and their impact, if any, on surveillance and diagnostic settings.

An electronic alert system increases screening for hepatitis B and C and improves management of patients with haematological disorders

Treatment of haematological disorders in patients with chronic hepatitis B or resolved infection (anti-HBc-positive) is associated with a risk of hepatitis B reactivation. Moreover, patients with chronic hepatitis C have a higher risk of haematological malignancies than general population. An electronic alert system was developed to promote screening of hepatitis B (HBV) and C (HCV) in patients starting haematological therapies. The system included screening and linkage to care and a request for testing in those without data. From March, 2017 to March, 2018 data from 420 consecutive patients with haematological diseases were included. At first prescription before the alerts, the HCV and HBV screening rate was 60.5%. Following the alerts, an additional 115 were screened, increasing the overall screening rate to 87.9%. Anti-HBc alone was detected in 57, anti-HCV in 13, and HBsAg in 2 patients. Overall, 68% of patients with any viral hepatitis markers were previously not know, and the impact was particularly important for anti-HBc detection (47/57 unknown). Nucleoside analogues were prescribed in 28 (49.1%) anti-HBc-positive and the 2 HBsAg-positive patients. Prospective follow-up with HBV DNA and HBsAg testing showed no cases of HBV reactivation. An estimated 1.2 HBV reactivations were avoided as consequence of the alert system. In summary, an electronic alert system increased viral hepatitis screening in patients receiving haematological treatment and led to improvements in the management of these patients, including avoided HBV reactivation.

Pattern of Liver Function Tests in Spectrum of Acute Viral Hepatitis

Objective: To find out the pattern of Liver Function tests (LFTs) in different spectrums of Acute Viral Hepatitis (AVH).Study Design: Cross sectional.Place and Duration of Study: The study was conducted at Pathology Department of Combined Military Hospital, Malir Karachi from March 2017 to August 2017.Materials and Methods: A total of 360 subjects of all age groups, both male and female, with biochemical features of acute viral hepatitis (AVH) were included. After clinical history and examination, liver function tests (LFTs) were performed that included total bilirubin, alanine amino transferases (ALT), alkaline phosphatase (ALP), followed by viral markers for hepatitis A virus (HAV), hepatitis B virus (HBV) hepatitis C virus (HCV) and hepatitis E virus (HEV).Results: Among the 360 patients studied, males (n=308, 86%) outnumbered females (n=52, 14%). Biochemical pattern showed ALT value reaching >75 times the upper limit of normal (ULN). Similarly rise of serum total bilirubin was up to 30 times of ULN while rise of serum ALP was not more than 5 times of ULN. HEV was found to be the most common (28%) in seropositive AVH in the study group. Highest number (24.4%) of HEV infection was found among males in the age group of 20-30 years. ALT and bilirubin were significantly raised in patients with HEV as compared to other causes of AVH.Conclusion: Pattern of LFTs varies in spectrum of AVH. Highest rise of ALT indicates extensive liver damage in HEV infection.
 How to cite this: Yousaf S, Younas M, Murtaza M, Akhtar F, Jaffar SR, Ijaz A. Pattern of Liver Function Test in Spectrum of Acute Viral Hepatitis. Life and Science. 2020; 1(1): 29-33. doi: http://doi.org/10.37185/L&S.1.1.38

Тhe role of the internal use of mineral water in the complex treatment of patients with chronic viral hepatitis C with concomitant non-alcoholic fatty liver disease

Introduction: The use of modern drugs with direct antiviral effect allows achieving a stable virologic response (SVR) in patients with chronic hepatitis C (CHC). However, in most cases, after the elimination of HCV infection, the progression of fibrosis continues with the development of its terminal stages and adverse outcomes for patients. The presence of non-alcoholic fatty liver disease (NAFLD) in these patients significantly increases the rate of progression of fibrosis and its complications, even after reaching SVR. Therefore, the search and development of new non-drug treatment technologies for this category of patients is relevant. Aim: to study the effectiveness of mineral water intake (with a high content of bicarbonates, sodium, potassium, and silicon compounds) in the new mode of use in the complex treatment of patients with chronic hepatitis C with concomitant NAFLD. Methods: anamnestic, clinical, general clinical, biochemical (indicators of lipid metabolism, HOMA index), serological (markers of viral hepatitis C, HCV RNA PCR, qualitative and quantitative determination, genotyping), ultrasonographic studies of the digestive system and statistical methods. Results: Patients with chronic hepatitis C (genotype 1b in the phase of replication, minimal and moderate activity) with concomitant NAFLD, which had been divided into two groups, were examined. Patients of group I (control group) received a standard complex of treatment (diet therapy that corresponded to the Mediterranean diet, dosed exercise regimen, antiviral therapy - sofosbuvir (400 mg) and ledipasvir (90 mg) - 3 months). Patients of group II (the main group) additionally received an internal course intake of mineral water (MW) according to our methodology: 3 ml per kg of patient’s body weight 30-40-60 min before meals, depending on the acidity in the stomach, and the same dose after food intake, three times a day (course - 2 months, a break - 2 months, a second course - 2 months). Evaluation of the effectiveness of treatment was carried out after six months from the start of treatment. Conclusion: The results prove the feasibility and effectiveness of using MW in a doubled dosage regimen in the complex treatment of patients with chronic hepatitis C with chronic concomitant NAFLD, which was determined by improving lipid metabolism, reducing signs of insulin resistance, improving ultrasonographic signs and preventing the development of fibrotic changes in the liver.

Clinical case of mixed infection of Viral hepatitis E and Infectious mononucleosis

The article considers a case from clinical practice: mixed infection of viral hepatitis E and infectious mononucleosis caused by Epstein-Barr virus in a boy of 15 years. The patient was long observed by a pediatrician with a diagnosis of lacunar tonsillitis, hospitalized on the 10th day of the disease in an infectious diseases hospital with a preliminary diagnosis of infectious mononucleosis. Objectively, in addition to acute tonsillitis, detected polylithionite, hepatosplenomegaly. The biochemical analysis of blood revealed a pronounced cytolysis syndrome, a study on the markers of viral hepatitis (revealed anti-HEV IgM). Discharged on the 28th day of the disease with residual effects.

Seroprevalence of viral hepatitis A, B, C, D and E viruses in the Hormozgan province southern Iran

BackgroundViral hepatitis is a global public health problem affecting millions of people worldwide, causing thousands of deaths due to acute and persistent infection, cirrhosis, and liver cancer. Providing updated serologic data can improve both surveillance and disease control programs. This study is aimed to determine the seroprevalence of markers for viral hepatitis (A, B, C, D and E) and the epidemiology of such infections in the general population of southern Iran’s Hormozgan province.MethodsBetween 2016 and 2017, a total of 562 individuals with ages ranging from 1 to 86 years, who visited governmental public laboratories for routine check-ups, were tested for the presence of serological markers to hepatitis virus types A to E using enzyme-linked immunosorbent assays.ResultsThe overall anti-hepatitis A virus (HAV) antibody seroprevalence was 93.2% (524/562). The prevalence of anti-hepatitis E virus (HEV) antibodies was 15.8% (89/562) among which 1.6% (9/562) of the seropositive individuals also had evidence of recent exposure to the virus (IgM positivity). Two and a half percent (14/562) were positive for hepatitis B surface (HBs) antigen, whereas 11.6% (65/562) tested positive for anti-hepatitis B core (HBc) antibodies. Among anti-HBc positive patients, 11% (7/65) had HBs Ag and 5% (3/65) were positive for anti-hepatitis D virus (HDV) antibodies. The prevalence of anti-hepatitis C virus (HCV) antibodies was 0.7% (4/562). The seroprevalence of anti-HAV, HEV IgG, anti-HBc antibodies, and HBs Ag increased with age.ConclusionThe present study confirms a high seroprevalence of HAV infection among the examined population and reveals high levels of endemicity for HEV in the region. Planned vaccination policies against HAV should be considered in all parts of Iran. In addition, improvements on public sanitation and hygiene management of drinking water sources for the studied area are recommended.

Rifampicin Induced Hyperbilirubinemias: A Case Report.

Abstract Anti-tubercular therapy (ATT) induced hepatitis is a major problem which a physician encounters in his clinical practice. A case of 28-year old female, weighing 45 kg was brought to hospital with the chief complains of low-grade fever for the past two months, cough, shortness of breath and 4-5 kg weight loss in two months. She had no history of hypertension (HTN), diabetes mellitus (DM), pulmonary tuberculosis (PTB). Her Chest X-ray showed right sided bilateral pulmonary TB and sputum acid fast bacilli (AFB) smear was repeatedly positive. Pulmonologist has started Category-I anti-tubercular regimen (Rifampicin, Isoniazid, Pyrazinamide and Ethambutol) under DOTS as per RNTCP guidelines. After 7 days of starting the treatment (DOTS regimen), she noticed yellowish discoloration of sclera, orange discoloration of urine but in spite of this she continued the drug for a further two weeks. Patient was found to be developing hepatotoxicity with the findings of elevated total bilirubin (10.2 mg/dl), conjugated bilirubin (2.5 mg/dl) and unconjugated bilirubin (7.2 mg/dl). Viral markers for hepatitis including hepatitis B viruses (HBsAg), hepatitis C viruses (HCV), human immunodeficiency virus (HIV), were all are non-reactive. Pulmonologist made provisional diagnosis of anti-tubercular drugs (specially rifampicin) induced hyperbilirubinemias. Pulmonologist initially hold Rifampicin and Pyrazinamide, but started Isoniazid, Ethambutol, Ofloxacin, Pyridoxine along with liver enzyme. She showed gradual improvement as bilirubin after one-week had dropped down to 1.2 mg/dl. Rifampicin was added to the regimen and the serum bilirubin checked after 1 week was found 1 mg/dl. Pyrazinamide was added after repeated LFTs showed normal values. Patient continued her drugs and came for review after three months. She was advised to continue and complete the course of anti-tubercular drugs. Since Rifampicin is the most important first line anti-tubercular drug it is very important to restart this drug in order to have a satisfactory response to anti-tubercular therapy. We have reported this case because of its rarity in clinical practice. As a health care team member clinical pharmacist are need to be made aware of these potentially fatal adverse effects associated with anti-tubercular therapy via conduction of quality-based seminars, published medical literature, conferences, learning programs and health care camps.

CLINICAL AND EPIDEMIOLOGICAL CHARACTERISTICS OF PATIENTS WITH HIV INFECTION

According to the latest data, in early 2018, 75% of HIV-positive people in the world knew about their HIV status (70% in early 2017); 79% of those who knew about their HIV status received treatment, 81% of those who received antiretroviral therapy have achieved an undetectable level of HIV viral load in the blood, i.e. less than 1000 RNA copies / ml. The purpose of the work is to find out the current clinical and epidemiological features of HIV infection, including in the Bukovina region. Materials and Methods: this prospective study for 2016 – 2018 included 292 HIV patients undergoing outpatient monitoring at the Chernivtsi Regional Center for AIDS Prevention and Control. All the subjects gave voluntary informed consent to participate in the study. Results and Discussion: Young people (25 – 44 years old) were predominantly included in the study; their total share among men was 88.3% and among women – 76.0%. There were slightly more female patients under 24 years of age (10.6% of female individuals versus 4.3% of male individuals) and within the 45-55 year old group (13.4% female participants versus 7.4% of male individuals). Clinical signs of stage III HIV infection found in 108 people included the manifestations of general intoxication syndrome forcing the participants to stay down in the bed up to a half a day. All the participants demonstrated the weight loss over 10% of that initially established; 34 (31.5%) patients had "unexplained" chronic diarrhoea over 3 times a day, which lasted more than a month. For 118 HIV-positive patients of the IV clinical stage, the fatigue syndrome (unexplained weight loss (more than 10% for 6 months) was the most indicative; this condition forced them to stay in bed for more than a half a day. Conclusions: Markers of hemocontact viral hepatitis were detected in 59.1% of patients with clinical stage I and II HIV infection, in 55.6% of the patients with III stage HIV and in 61.0% with stage IV of the disease.

Functional activity of blood phagocytes in opistorchiasis patients

Introduction. The urgency of the problem of opistorchiasis is dictated by the long clinical course of the disease with the possibility of formation of hepatobiliary pathology, including cancer. Aim. To study the peculiarities of the production of active oxygen forms of blood phagocytes in patients with opistorchiasis. Material and methods. A total of 42 patients with chronic opisthorchiasis (22 men and 20 women) and 35 apparently healthy patients (18 men and 17 women) between the ages of 24 and 45 were examined. Opistorchiasis was diagnosed by three methods: microscopic examination of duodenal bile, coproovoscopy and serological method. The control group was composed of healthy individuals who underwent routine medical examinations, which included biochemical blood tests, identification of markers for viral hepatitis and antibodies to opistorchs. The culture of neutrophils and blood monocytes was isolated by fractionation of cells on the ficoll with subsequent cleaning from adhering cells. Functional activity of neutrophils and blood monocytes was estimated by chemiluminescence method on production of active oxygen species: basic and after induction with zymosan. Results. In patients with opistorchiasis in comparison with healthy people, in neutrophil granulocytes, the maximum intensity of active oxygen species production decreased and the time to reach the maximum of active oxygen species production was increased both in spontaneous and zymosan-induced reactions in luminoland lucigenin-dependent processes. In monocytes during spontaneous reaction study it was discovered that the maximum intensity of oxygen production in luminoland lucigenindependent processes decreased and the time of reaching the maximum of oxygen production in luminol-dependent process increased in opistorchiasis patients in comparison with healthy people. When studying the zymosan-induced reaction in monocytes, a decrease in the maximum intensity of active oxygen species production in both reactions and an increase in the time to reach the maximum output of active oxygen species in the luminol-dependent process was registered in patients with opistorchiasis in comparison with healthy people. Conclusion. The data obtained indicate low functional activity of blood phagocytes in patients with chronic opistorchiasis in comparison with healthy people.

2458 Autoimmune Hepatitis-Induced Hepatic Lobar Atrophy

INTRODUCTION: Lobar atrophy of the liver can be a morphologic manifestation of benign and malignant liver or biliary duct disease. Rarely has it been associated with autoimmune hepatitis (AIH). CASE DESCRIPTION/METHODS: A 26 year old woman presented with a 2 month history of severe RUQ abdominal pain associated with anorexia, 10 lb weight loss, pruritus, and scleral icterus. Physical exam was notable for cachexia, jaundice, abdominal distension and tender hepatomegaly. Initial labs revealed: hemoglobin 10.1 g/dl, MCV 80, platelets 107, AST 968 U/L, ALT 487 U/L, ALP 369 U/L, total bilirubin 12.0 mg/dl, DB 9.0 mg/dl, total protein 6.4 g/dL, albumin 2.1 g/dl and INR 1.65. Serological data were as follows: AMA <1:20; ANA 1:160; and anti-smooth muscle antibody 1:20. Viral markers for hepatitis A, B and C were negative. CT abdomen revealed a large area of infiltrative hypoattenuation of the right hepatic lobe. Abdominal MRI noted a diffuse edema within both hepatic lobes. N-acetylcysteine was started for impending acute liver failure and prednisone for AIH. She improved clinically. A liver biopsy done showed diffuse liver cell necrosis with lobular collapse, acute and chronic inflammation in the portal tracts, and in the interface. She was deemed stable for discharge to return to clinic but she was lost to follow up. A year later, she returned with worsening RUQ pain, further weight loss of 30 pounds. Her LFTs were within normal limits but a CT abdomen showed portal hypertension, hypoattenuation of the right lobe, and cirrhosis with left hepatic lobe atrophy. Azathioprine was started in addition to Prednisone. DISCUSSION: This patient's left lobar atrophy was not deemed to be congenital due to the presence of the left hepatic lobe on prior imaging studies. Hepatic neoplasms which can as well cause lobar atrophy was also ruled out with imaging. This is one of the few reported cases of hepatic lobar atrophy attributed to AIH which is a chronic disease characterized by increased autoantibodies in circulation and inflammation around the portal vein. This inflammation can result in lobar atrophy via occlusion of the portal vein resulting in impairment of liver blood flow as well as a reduction in the supply of hepatotrophic substances, particularly insulin. This may cause ischemia in certain areas of the liver and subsequently, atrophy secondary to necrosis and apoptosis. This patient also had significant cholestasis on initial presentation which could also contribute to cellular apoptosis through the Fas ligand pathway.

2421 A Case of Acute Liver Injury Caused by an Herbal Supplement Containing Saw Palmetto: “Good for the Prostate but Not for the Liver”

INTRODUCTION: Saw palmetto (Serenoa repens), an herbal product used for benign prostatic hyperplasia, is a part of many herbal and dietary supplements (HDS) used for bodybuilding. It is associated with a hepatocellular pattern of acute liver injury. We present a case of liver injury secondary to supplement containing saw palmetto, which improved upon discontinuation. CASE DESCRIPTION/METHODS: A 36-year-old man with history of gastric bypass surgery was admitted with vomiting and diarrhea for the last 2 days. Abdominal examination was unremarkable. Labs revealed ALT of 2200 U/L, AST of 800 U/L with normal bilirubin, alkaline phosphatase and INR. Abdominal ultrasound revealed gallstones with a normal bile duct. Work up for infectious diarrhea was unremarkable. The symptoms were attributed to acute viral gastroenteritis. A diagnosis of acute liver injury was made, and further tests were performed to establish the etiology. Viral markers for Hepatitis A, B, C, E, Epstein Barr, Herpes simplex and Cytomegalovirus were all negative. The ANA, ASMA, ceruloplasmin and acetaminophen levels were unremarkable. He denied any alcohol use. Further history revealed that he had been using an over the counter herbal product to boost the testosterone levels to increase the muscle mass for the last one month. The ingredients of the product included saw palmetto and other herbal constituents. Review of the literature showed an association between saw palmetto and hepatocellular type of liver injury. The liver injury was attributed to the supplement and the cessation was advised. Follow up 4 weeks later showed normalization of the liver profile. DISCUSSION: HDS induced liver injury accounts for 20% cases of hepatotoxicity and 13% cases of acute liver failure in America. Many such cases are due to MINS (multi ingredient nutritional supplements), and the component responsible for the toxicity is usually unknown or can only be suspected. One of such ingredients used in these products is sawPalmetto which may cause supplement-induced liver injury. The latency to onset is within 1 to 2 weeks, and the clinical features resemble acute viral hepatitis with a hepatocellular pattern of liver enzyme elevations. Liver injury is probably an idiosyncratic phenomenon and usually resolves in 1 to 3 months. HDS-induced liver injury presents many challenges in diagnosis, identification of the responsible constituents, treatment and prevention. The regulation of non-prescription products to guarantee public safety is very important.

Coexistent ipsilateral venous sinus thrombosis and arterial stroke in iron deficiency anemia

Concomitant ipsilateral cerebral venous sinus thrombosis and arterial infarction are exceedingly rare clinical entity. We suggest that iron deficiency anemia caused the simultaneous affection of the two arterial beds. We report a 34-year-old right-handed male who presented with headache, vomiting, left hemiplegia and drowsiness. On arrival to ER, he had hypotension and sinus bradycardia necessitating inotropic support. He was drowsy and had signs of right middle cerebral artery involvement confirmed by unenhanced CT brain showing acute right temporo-parietal ischemic infarction. The investigations revealed anemia (Hb 8.8 g/dL, MCV 57.7fL), hypoferritinemia (<5 ng/mL) and hypochromic microcytic anemia suggesting iron deficiency anemia. Other investigations including inflammatory markers, bacterial cultures, anticoagulation profile, lipids, glycemic indices, Hb Electrophoresis, autoimmune markers including antiphospholipid syndrome, cryoglobulins, thrombophilia screen, viral markers for hepatitis B and C as well as HIV were negative. The echocardiogram and a pan CT abdomen and chest were unremarkable. A repeat CT brain on the same day revealed right middle cerebral artery territory infarction with hyperdense right transverse and sigmoid sinuses. CT cerebral angio- and venogram showed dural sinus thrombosis involving the right transverse and sigmoid sinuses, jugular bulb and proximal jugular vein along with linear filling defect at the origin of the right internal carotid artery. Later, he underwent decompressive hemicraniectomy. He received blood transfusions, iron supplementations and therapeutic anticoagulation. Inotropic support was weaned off gradually. Neurologically, residual hemiplegia prevailed.

SERONEGATIVE AUTOIMMUNE HEPATITIS – A CASE REPORT

Autoimmune hepatitis (AIH) is a complex liver disease. It is reported in children and adults of all age groups. An 11-year-old male&nbsp;child was admitted in our hospital for anorexia and yellowish discoloration of eyes, skin, and urine for 2 months. He had fever,&nbsp;itching was passing pale-colored stools. The child had hepatosplenomegaly and viral hepatitis markers as well as autoimmune&nbsp;markers were negative. Liver biopsy was suggestive of AIH. The child was started on prednisolone and showed drastic improvement&nbsp;clinically as well as biochemically. This was a case of seronegative AIH, which responded very well to corticosteroids. Hence, high&nbsp;index of suspicion is required to diagnose the case of seronegative AIH.

2619 Persistently Elevated Intestinal Alkaline Phosphatase in an Individual With AB Blood Group: A Rare Presentation

INTRODUCTION: Elevated alkaline phosphatase (ALP) is seen in hepatobiliary and bone diseases. However, elevated intestinal ALP has been reported in the literature in association with blood group B or O, whose clinical significance is not known. We present a rare case of persistently elevated intestinal ALP in an individual with blood group AB. CASE DESCRIPTION/METHODS: A 56-year-old female presented to our ambulatory clinic to establish health care. Her medical history included peptic ulcer disease and dyslipidemia. She underwent appendectomy in childhood and cholecystectomy around 20 years ago. she denied smoking, alcohol consumption or use of recreational drugs. Family history was significant for type 1 DM in mother and brother. Her only medication included ranitidine. General and systemic examination was normal. Her initial labs were normal except elevated alkaline phosphatase of 359 units/liter. The patient was seen by the gastroenterology team. Further laboratory workup including viral hepatitis, metabolic and autoimmune markers of liver disease were normal. Gamma-glutamyltransferase (GGT), Vitamin D and parathyroid profile were normal. Ultrasound abdomen did not show any significant lesion in the liver or biliary tree. As no evidence of liver disease was noted isoenzyme electrophoresis of ALP was ordered which showed elevated intestinal ALP fraction of 64% (normal 1–24%). Patient blood group was tested which showed group AB. On further follow up in gastroenterology clinic persistently elevated ALP noted. DISCUSSION: Elevated intestinal alkaline phosphatase has been reported in maintaining of gut hemostasis and elevated levels noted in various pathological conditions of the gastrointestinal tract. Meal induced elevation of intestinal ALP has been proposed as a treatment modality to preserve gut hemostasis and minimize inflammation. To the best of our knowledge, our case is an extremely rare presentation of elevated intestinal ALP in an individual with blood group AB. Further molecular and genetic studies in the future may help elaborate functions and therapeutic intervention of intestinal ALP

1429 Choledocholithiasis in Primary Hepatic Lymphoma (PHL): An Additional Hurdle to PHL Diagnosis?

INTRODUCTION: Primary hepatic lymphoma (PHL) is a rare disorder involving solely liver at the time of initial presentation. Diffuse large B-cell lymphoma (DLBCL) variant in PHL is scarce. Patients with Immune suppression and HIV infection are at increased risk for the PHL-DLBCL variant. We present an individual, whose initial clinical presentation is masked my choledocholithiasis, subsequently diagnosed with PHL-DLBCL by histopathology. CASE DESCRIPTION/METHODS: A 59-year-old-man with prostate cancer (Gleason score of 7) managed conservatively for the last two years presented to the ED with intermittent epigastric pain of one-week duration associated with subjective fever and night sweats. On examination, he was afebrile and hemodynamically stable. The liver was palpable below the right costal margin and found to have inguinal lymphadenopathy. The laboratory data revealed obstructive jaundice with a cholestatic pattern (Table 1). Abdominal U/S and MRCP revealed cholelithiasis with normal biliary anatomy. Viral hepatitis, autoimmune and metabolic markers of liver disease were normal. Given the worsening of the obstructive pattern of liver tests, the patient underwent ERCP which showed two small stones in the distal CBD. Cholestasis improved, and the patient was discharged home in stable condition. Three weeks later he was readmitted with significant weight loss, malaise and night sweats. The laboratory investigation showed worsening of cholestasis with no imaging evidence of biliary stent obstruction. Hence, liver biopsy was performed to evaluate infiltrative liver disease. His hospital course was complicated by multiple organ failure requiring mechanical ventilator support and renal replacement therapy. Despite all resuscitative efforts, patient's general condition deteriorated and expired. His liver biopsy was reported with findings suggestive of DLBCL. Extrahepatic involvement was ruled out by negative lymph node biopsy. DISCUSSION: PHL is very rare primary hepatic malignancy and, DLBCL variant is extremely rare. As laboratory and imaging findings in PHL are non-specific, it is difficult to distinguish from infiltrative, granulomatous and other malignant liver diseases. Liver biopsy is essential for diagnosis and identifying the immunophenotype. It is vital to consider this condition as outcomes in PHL vary from other liver diseases. Our patient is a unique example where coexistent choledocholithiasis posed a diagnostic challenge like prior reported cases in literature.