Case Reports in Hepatology The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Hepatorenal Syndrome with Cirrhotic Cardiomyopathy: Case Report and Literature Review Sun, 22 Mar 2015 10:58:49 +0000 The hepatorenal syndrome (HRS) is defined as a potentially reversible kidney failure in patients with cirrhosis and ascites. An association of HRS and cirrhotic cardiomyopathy has been reported recently, but there are no result studies about the use of positive inotropes as part of the acute phase treatment. We report the case of a patient diagnosed with HRS, with high levels of NT pro-BNP, but with normal ejection fraction of the left ventricle, which showed abnormalities in systolic function through speckle tracking in echocardiography, reversible after the infusion of dobutamine. The patient showed clinical and laboratory improvement of his renal function after the infusion of dobutamine. Clinical studies are needed on HRS therapeutic approach taking into account the myocardial dysfunction as a major contributing factor to renal dysfunction. Luis Mocarzel, Pedro Lanzieri, Juliana Nascimento, Clara Peixoto, Mário Ribeiro, and Evandro Mesquita Copyright © 2015 Luis Mocarzel et al. All rights reserved. Corrigendum to “Asymptomatic Liver Abscesses Mimicking Metastases in Patients after Whipple Surgery: Infectious Complications following Percutaneous Biopsy—A Report of Two Cases” Tue, 03 Feb 2015 09:22:14 +0000 Kan K. Zhang, Majid Maybody, Rajesh P. Shah, Efsevia Vakiani, George I. Getrajdman, Lynn A. Brody, and Stephen B. Solomon Copyright © 2015 Kan K. Zhang et al. All rights reserved. Acute Viral Hepatitis E Is Associated with the Development of Myocarditis Sat, 31 Jan 2015 08:15:19 +0000 Myocarditis, an inflammatory disease of heart muscle, is an important cause of dilated cardiomyopathy worldwide. Viral infection is an important cause of myocarditis. This condition presents with various symptoms, ranging from minimally symptomatic cases to fatal arrhythmia and cardiogenic shock, and may develop chronic myocarditis and dilated cardiomyopathy in some patients. We report the case of a 26-year-old patient with acute viral hepatitis E who developed symptomatic myocarditis. As far as we could search, this is probably the 3rd case report of this rare association. M. Premkumar, Devraja Rangegowda, Chitranshu Vashishtha, Vikram Bhatia, Jelen Singh Khumuckham, and Badal Kumar Copyright © 2015 M. Premkumar et al. All rights reserved. Severe Aplastic Anemia following Acute Hepatitis from Toxic Liver Injury: Literature Review and Case Report of a Successful Outcome Mon, 22 Dec 2014 06:26:13 +0000 Hepatitis associated aplastic anemia (HAAA) is a rare syndrome in which severe aplastic anemia (SAA) complicates the recovery of acute hepatitis (AH). HAAA is described to occur with AH caused by viral infections and also with idiopathic cases of AH and no clear etiology of liver injury. Clinically, AH can be mild to fulminant and transient to persistent and precedes the onset SAA. It is assumed that immunologic dysregulation following AH leads to the development of SAA. Several observations have been made to elucidate the immune mediated injury mechanisms, ensuing from liver injury and progressing to trigger bone marrow failure with the involvement of activated lymphocytes and severe T-cell imbalance. HAAA has a very poor outcome and often requires bone marrow transplant (BMT). The findings of immune related myeloid injury implied the use of immunosuppressive therapy (IST) and led to improved survival from HAAA. We report a case of young male who presented with AH resulting from the intake of muscle building protein supplements and anabolic steroids. The liver injury slowly resolved with supportive care and after 4 months of attack of AH, he developed SAA. He was treated with IST with successful outcome without the need for a BMT. Kamran Qureshi, Usman Sarwar, and Hicham Khallafi Copyright © 2014 Kamran Qureshi et al. All rights reserved. Safe and Successful Yttrium-90 Resin Microsphere Radioembolization in a Heavily Pretreated Patient with Chemorefractory Colorectal Liver Metastases after Biliary Stent Placement above the Papilla Wed, 17 Dec 2014 06:41:51 +0000 We report a case of safe and successful yttrium-90 resin microsphere radioembolization in a patient with a long history of multiple recurrent colon cancer hepatic metastases progressing after hepatic resections, hepatic arterial chemotherapy, and multiple regimens of systemic chemotherapy. One month prior to radioembolization, a biliary stent was placed above the level of the ampulla to relieve tumor-related biliary obstruction and normalize bilirubin levels. Vlasios S. Sotirchos, Elena N. Petre, Karen T. Brown, Lynn A. Brody, Michael I. D’Angelica, Ronald P. DeMatteo, Nancy E. Kemeny, and Constantinos T. Sofocleous Copyright © 2014 Vlasios S. Sotirchos et al. All rights reserved. Right Gastroepiploic Artery as an Alternative for Arterial Reconstruction in Living Donor Liver Transplantation Sun, 16 Nov 2014 00:00:00 +0000 Background. An adequate blood flow is directly related to graft survival in living donor liver transplantation. However, in some cases, unfavorable conditions prevent the use of the hepatic artery for arterial reconstruction. Herein, we report a case in which the recipient right gastroepiploic artery was used as an option for arterial reconstruction in adult-to-adult living donor liver transplantation. Case Report. A 62-year-old woman, with cirrhosis due to hepatitis B associated with hepatocellular carcinoma, was submitted to living donor liver transplantation. During surgery, thrombosis of the hepatic artery with intimal dissection until the celiac trunk was observed, which precluded its use in arterial reconstruction. We decided to use the right gastroepiploic artery for arterial revascularization of the liver graft. Despite the discrepancy in size between donor hepatic artery and recipient right gastroepiploic artery, anastomosis was performed successfully. Conclusions. The use of the right gastroepiploic artery as an alternative for arterial revascularization of the liver graft in living donor liver transplantation should always be considered when the hepatic artery of the recipient cannot be used. For performing this type of procedure, familiarity with microsurgical techniques by the surgical team is necessary. Klaus Steinbrück, Reinaldo Fernandes, Marcelo Enne, Rafael Vasconcelos, Giuliano Bento, Gustavo Stoduto, Thomas Auel, and Lúcio Filgueiras Pacheco-Moreira Copyright © 2014 Klaus Steinbrück et al. All rights reserved. Leptomeningeal Dissemination in Gall Bladder Carcinoma: Sequelae of Long-Term Survival? Wed, 05 Nov 2014 13:20:07 +0000 Patients with gall bladder malignancies usually present at an advanced stage with less than 20% cases being resectable at presentation and over a half harbouring distant metastases to liver or paraaortic nodes. Long-term cure is uncommon and so is the presence of central nervous system metastases. We present the case of a middle-aged woman with adenocarcinoma gall bladder, treated with postoperative locoregional irradiation following simple cholecystectomy, who developed headache, backache, vision loss, and multiple joint pains six years following adjuvant therapy. A diagnosis of leptomeningeal carcinomatous meningitis was established with cerebrospinal fluid cytology positivity for carcinoma. She deteriorated on palliative cranial irradiation and was managed with best supportive care. Shikha Goyal and Bidhu Kalyan Mohanti Copyright © 2014 Shikha Goyal and Bidhu Kalyan Mohanti. All rights reserved. Bleeding Ectopic Varices as the First Manifestation of Portal Hypertension Mon, 22 Sep 2014 08:19:33 +0000 Ectopic varices are defined as dilated portosystemic collateral veins in locations other than the gastroesophageal region. We present a case of recurrent upper gastrointestinal bleeding as the first manifestation of portal hypertension. We diagnosed ectopic duodenal varices without gastroesophageal varices on upper GI endoscopy and extrahepatic portal venous obstruction (EHPVO) on CT angiography and managed this case. Brij Sharma, Sujeet Raina, and Rajesh Sharma Copyright © 2014 Brij Sharma et al. All rights reserved. Autoimmune Cholangitis: A Variant Syndrome of Autoimmune Hepatitis Sun, 21 Sep 2014 09:32:37 +0000 Autoimmune cholangitis (AIC) or autoimmune cholangiopathy is a chronic inflammation of liver and a variant syndrome of autoimmune hepatitis (AIH). We present a case of an adult female who had biochemical features of cholestasis and transaminasemia but aminotransferases were not in the hepatitis range and had histological evidence of bile duct injury which was subsequently diagnosed as autoimmune cholangitis. Brij Sharma, Sujeet Raina, and Rajesh Sharma Copyright © 2014 Brij Sharma et al. All rights reserved. The Possible Efficacy of Artichoke in Fluconazole Related Hepatotoxicity Wed, 03 Sep 2014 06:30:07 +0000 Although fluconazole related hepatotoxicity (FRH) is rare, mortal acute hepatic necrosis and jaundice were reported in immunocompromised states such as acquired immunodeficiency syndrome (AIDS) and bone marrow transplant (BMT). We present a case of a patient with multiple sclerosis who developed hepatotoxicity with the use of a single 150 mg fluconazole tablet for fungal vaginitis, 10 days after methylprednisolone pulse treatment. Our patient’s alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels were decreased, 1200 U/L and 800 U/L, respectively, and bilirubin levels were consistent at 37 mg/dL. Artichoke which has anticholestatic and antioxidant properties was used by our patient. She consumed a 30 mg artichoke leaf extract tea 3 times a day. The bilirubin levels significantly declined at the end of the first week and all liver function tests were normalized within 2 months. Hüseyin Kurt, Omer Toprak, and Erdoğan Bülbül Copyright © 2014 Hüseyin Kurt et al. All rights reserved. Response to “Acute Hepatitis Induced by Lyprinol, the Lipid Extract of the Green-Lipped Mussel (Perna canaliculus), in a Patient with Polyarthrosis” Wed, 20 Aug 2014 09:05:57 +0000 Stephen P. Myers and Christopher J. Oliver Copyright © 2014 Stephen P. Myers and Christopher J. Oliver. All rights reserved. Liver Metastases of Unknown Primary: Malignant Melanoma Sun, 20 Jul 2014 11:51:25 +0000 According to the National Cancer Institute’s (NCI) data, the increase in the number of patients diagnosed with malignant melanoma was found to be at a higher rate than the current increase in all other types of cancer (Jemal et al., 2008). Early diagnosis, appropriate surgical treatment, and chemotherapy have positive impacts on the course of the disease but despite these developments on the treatment, current prognosis of metastatic malignant melanoma prognosis is still extremely poor. Life expectancy in patients with metastatic disease is between 2 and 8 months. The 5-year disease-free survival rate is identified in only 5% of the patients (Leong, 2003) (Kirkwood et al., 1996). In this study, we try to report a patient with metastatic malignant melanoma and give recent informations about the liver metastases of malignant melanoma. Ozgur Bostanci, Kinyas Kartal, and Muharrem Battal Copyright © 2014 Ozgur Bostanci et al. All rights reserved. External Hemorrhage from a Portacaval Anastomosis in a Patient with Liver Cirrhosis Tue, 08 Jul 2014 13:08:06 +0000 Variceal bleeding is the major complication of portal hypertension in patients with liver cirrhosis. Hemorrhage mainly occurs in gastrointestinal lumen. Extraluminal hemorrhages are quite rare, such as intraperitoneal hemorrhages. We aimed to present a variceal bleeding case from the anastomosis on the anterior abdominal wall, as an extraordinary bleeding location, in a patient with portal hypertension in whom there were no esophageal and gastric varices. Murat Biyik, Ramazan Ucar, Sami Cifci, Orhan Ozbek, Gokhan Gungor, Ozlem Ozer Cakir, Fatma Yavuz, Huseyin Ataseven, and Ali Demir Copyright © 2014 Murat Biyik et al. All rights reserved. Low-Dose Tolvaptan for the Treatment of Dilutional Hyponatremia in Cirrhosis: A Case Report and Literature Review Wed, 30 Apr 2014 10:59:41 +0000 Dilutional hyponatremia is common in decompensated cirrhosis and can be successfully treated by tolvaptan, a vasopressin V2-receptor antagonist. Data were lacking regarding the effects of tolvaptan on cirrhotic patients with a Child-Pugh score of >10 and a serum sodium concentration of <120 mmol/L. We report a case of forties man with a 20-year history of chronic hepatitis B presenting with yellow urine and skin. Laboratory tests demonstrated prolonged prothrombin time, markedly elevated total bilirubin, severe hyponatremia, and a Child-Pugh score of >10. The patient was diagnosed with dilutional hyponatremia and was treated with recommended dosage tolvaptan at first. The serum concentration of sodium recover but the patient felt obviously thirsty. As the dosage of tolvaptan was decreased accordingly from 15 mg to 5 mg, the patient still maintained the ideal concentration of serum sodium. This case emphasizes that cirrhotic patient with higher Child-Pugh scores and serum sodium concentration of <120 mmol/L can be treated with lower dose of tolvaptan. Guo Shen and Hainv Gao Copyright © 2014 Guo Shen and Hainv Gao. All rights reserved. The Successful Use of Inhaled Nitric Oxide in the Management of Severe Hepatopulmonary Syndrome after Orthotopic Liver Transplantation Thu, 03 Apr 2014 07:01:08 +0000 Hepatopulmonary syndrome (HPS) is characterized by pulmonary vasodilation and subsequent hypoxemia in the setting of hepatic dysfunction. There is currently no pharmacologic intervention that has been shown to significantly affect outcomes and liver transplantation remains the mainstay of therapy. Unfortunately, patients undergoing liver transplantation are at high risk of significant hypoxemia and mortality in the early postoperative period. In the following case series, we present two cases of patients with severe HPS who underwent liver transplantation and experienced marked hypoxemia in the early postoperative period. In both cases, we successfully treated the patients with inhaled nitric oxide for their severe refractory life-threatening hypoxemia which led to immediate and dramatic improvements in their oxygenation. Although the use of inhaled nitric oxide in patients with HPS has been sporadically reported in pediatric literature and in animal studies, to our knowledge, our cases are the first recorded in adult patients. Joshua Santos, Philip Young, Igor Barjaktarevic, Catherine Lazar, Irawan Susanto, and Tisha Wang Copyright © 2014 Joshua Santos et al. All rights reserved. Nonalcoholic Steatohepatitis in a Patient with Ataxia-Telangiectasia Mon, 06 Jan 2014 12:05:24 +0000 Ataxia-telangiectasia (A-T) is a rare disease characterized by neurodegenerative alterations, telangiectasia, primary immunodeficiency, extreme sensitivity to radiation, and susceptibility to neoplasms. A-T patients have inactivation of ataxia-telangiectasia-mutated (ATM) protein, which controls DNA double-strand break repair and is involved in oxidative stress response, among other functions; dysfunctional control of reactive oxygen species may be responsible for many of the clinical manifestations of this disease. To the best of our knowledge, hepatic lesions of steatohepatitis have not previously been reported in A-T patients. The present study reports the case of a 22-year-old man diagnosed with A-T at the age of 6 years who was referred to our Digestive Disease Unit with a three-year history of hyperlipidemia and liver test alterations. Core liver biopsy showed similar lesions to those observed in nonalcoholic steatohepatitis. Immunohistochemical staining disclosed the absence of ATM protein in hepatocyte nuclei. We suggest that the liver injury may be mainly attributable to the oxidative stress associated with ATM protein deficiency, although other factors may have made a contribution. We propose the inclusion of A-T among the causes of nonalcoholic steatohepatitis, which may respond to antioxidant therapy. Trinidad Caballero, Mercedes Caba-Molina, Javier Salmerón, and Mercedes Gómez-Morales Copyright © 2014 Trinidad Caballero et al. All rights reserved. Granulomatous Hepatitis Secondary to Histoplasma Infection after Treatment with Infliximab Sat, 14 Dec 2013 10:09:31 +0000 Classical presentation of Histoplasma infection includes fever and respiratory symptoms. Opportunistic microorganisms must be suspected on immunocompromised patients who develop bizarre symptoms. We present a case of a female patient with rheumatoid arthritis who received treatment with Infliximab during one and a half year; she developed granulomatous hepatitis secondary to Histoplasma infection. The patient was admitted with acute hepatitis and thrombocytopenic coagulopathy. A liver biopsy was performed revealing granulomatous hepatitis, microvesicular steatosis, isolated apoptotic cells, and parenchyma microabscesses. PAS and Gömöri stains revealed areas with mycotic microorganisms morphologically compatible with Histoplasma spp. and confirmed by culture. L. Barrera, J. Álvarez, M. Tapias, V. Idrovo, and R. López Copyright © 2013 L. Barrera et al. All rights reserved. An Unusual Congenital In Situ Malrotation of the Liver Tue, 03 Dec 2013 10:04:52 +0000 Congenital anomaly of the liver is an uncommon and usually incidental finding. This report describes a case of in situ liver malrotation that has never been reported in the literature. Published literature relevant to the finding are briefly discussed. Hua Zhong Copyright © 2013 Hua Zhong. All rights reserved. Fulminant Liver Failure Associated with Abdominal Crush Injury in an Eleven-Year Old: A Case Report Tue, 22 Oct 2013 14:19:26 +0000 An 11-year-old obese male was involved in an all-terrain vehicle rollover accident. He had elevated transaminase levels along with a lactic acidosis. The imaging studies did not reveal any major intra-abdominal or thoracic injuries. The physical exam was unremarkable. The patient had an unremarkable PICU course and was transferred to the floor the next day. Within 24 hours of his transfer, he was noted to have interval worsening in liver function tests. He developed fulminant liver failure (FLF), renal failure, and encephalopathy. An ultrasound of the liver revealed increased echogenicity in the right lobe with focal sparing. Patient was listed for transplant. Investigations into any underlying medical cause of FLF were negative. Liver failure was presumed to be related to ischemia/reperfusion injury of the liver. The renal failure was due to rhabdomyolysis and was supported with renal replacement therapy. Patient received supportive care for FLF and was noted to have significant recovery of liver and renal function with time. He was discharged home after a 3-week hospitalization. Patients with crush abdominal injuries and elevated transaminase levels without evidence of parenchymal liver disruption may need to be closely monitored for liver failure related to ischemia reperfusion. Erin Gordon and Sameer Kamath Copyright © 2013 Erin Gordon and Sameer Kamath. All rights reserved. Spontaneous Bacterial Peritonitis Caused by Listeria monocytogenes Associated with Ascitic Fluid Lymphocytosis: A Case Report and Review of Current Empiric Therapy Sun, 15 Sep 2013 10:35:24 +0000 Spontaneous bacterial peritonitis (SBP) is a potentially deadly complication of ascites. We describe a case of SBP caused by Listeria monocytogenes in a patient with alcoholic cirrhosis. This was associated with the unusual finding of ascitic fluid lymphocytosis, which previously had only been associated with tuberculoid or malignant ascites. Given increasing rates of cefotaxime-resistant SBP alongside the possibility of Listeriosis, the use of cefotaxime as first-line therapy in SBP should be reevaluated. Todd Yecies and Sanae Inagami Copyright © 2013 Todd Yecies and Sanae Inagami. All rights reserved. Transjugular Retrograde Obliteration prior to Liver Resection for Hepatocellular Carcinoma Associated with Hyperammonemia due to Spontaneous Portosystemic Shunt Mon, 19 Aug 2013 08:57:34 +0000 A 67-year-old woman had hepatocellular carcinoma (HCC) measuring 3.7 cm at S8 of the liver with hyperammonemia due to a spontaneous giant mesocaval shunt. Admission laboratory data revealed albumin, 2.9 g/dL; total bilirubin, 1.3 mg/dL; plasma ammonia level (NH3), 152 g/dL; total bile acid (TBA) 108.5 μmoL/L; indocyanine green retention rate at 15 min (ICG15), 63%. Superior mesenteric arterial portography revealed a hepatofugal giant mesocaval shunt, and the portal vein was not visualized. Before surgery, transjugular retrograde obliteration (TJO) for the mesocaval shunt was attempted to normalize the portal blood flow. Via the right internal jugular vein, a 6 F occlusive balloon catheter was inserted superselectively into the mesocaval shunt. The mesocaval shunt was successfully embolized using absolute ethanol and a 50% glucose solution. Eleven days after TJO, NH3, TBA, and ICG15 decreased to 56, 44, and 33, respectively. Superior mesenteric arterial portography after TJO revealed a hepatopetal portal flow. Partial hepatectomy of S8 was performed 25 days after TJO. The subsequent clinical course showed no complications, and the woman was discharged on postoperative day 14. We conclude that the combined therapy of surgery and TJO is an effective means of treating HCC with hyperammonemia due to a spontaneous portosystemic shunt. Fumio Chikamori and Nobutoshi Kuniyoshi Copyright © 2013 Fumio Chikamori and Nobutoshi Kuniyoshi. All rights reserved. Severe Starvation-Induced Hepatocyte Autophagy as a Cause of Acute Liver Injury in Anorexia Nervosa: A Case Report Tue, 30 Jul 2013 14:34:52 +0000 Introduction. Mild elevation of transaminase may be observed in anorexia nervosa, but acute liver injury is uncommon. A complex programmed cell death in response to starvation, called autophagy, has been described in experimental and human studies. Case Presentation. A 24-year-old woman suffering from anorexia nervosa was hospitalized for severe malnutrition. At admission, there were biological signs of acute liver injury but no electrolytic imbalance. After having ruled out the most common causes of liver injury, the patient was carefully refed. As liver tests remained abnormal, liver biopsy was performed. At histology and electron microscopy, numerous signs suggestive of starvation-induced hepatocyte autophagy were found. Discussion. Severe starvation can be associated with acute liver injury that is slowly reversible with careful enteral nutrition. In this clinical situation, profound hepatic glycogen depletion in association with autophagy appears as the leading cause of liver injury. S. Restellini, L. Spahr, and L. Rubbia Brandt Copyright © 2013 S. Restellini et al. All rights reserved. Death from Liver Failure despite Lamivudine Prophylaxis during R-CHOP Chemotherapy due to Rapid Emergence M204 Mutations Tue, 30 Jul 2013 08:06:55 +0000 Background. Rapid and early emergence of clinically significant LAM resistance is thought to be unlikely during the first year of treatment, and as a result LAM is thought to be a reasonable choice as a first line agent for prophylaxis during chemotherapy. Aim. To report fatal HBV reactivation despite appropriate LAM prophylaxis in two previously treatment-naive individuals undergoing R-CHOP chemotherapy. Case Presentation. Case 1 is a 65-year-old man with chronic HBV infection: HBeAg-negative, HBV DNA 6.65E5 IU/mL, ALT 43 IU/L, and Fibroscan 4.4 kPa, consistent with F0, who was diagnosed with lymphoma that was treated with R-CHOP and LAM prophylaxis. HBV DNA fell to 2.18E1 IU/mL within 2 months of starting LAM. Four months after chemotherapy, despite ongoing LAM of 7-month duration with confirmed adherence, severe asymptomatic hepatitis was noted during routine monitoring with ALT 1019 IU/L, HBeAg negative, HBV DNA 1.43E7 IU/mL, and genotyping confirmed L80I and M204I mutations. He died 14 days after flare diagnosis despite a switch to tenofovir (HBV DNA had fallen to 1.94E5 IU/mL 2 weeks after starting tenofovir). Case 2 is a 50-year-old man who was found to have HBeAg-negative hepatitis B, ALT 37 IU/L, and no clinical features of cirrhosis (platelets 283, APRI 0.19) after lymphoma diagnosis. Lymphoma was treated with R-CHOP and LAM prophylaxis. Pretreatment HBV DNA was not done but was 8.90E4 IU/mL 3 weeks after starting LAM and 3.96E3 IU/mL 3 months after starting LAM. Two months after chemotherapy, despite ongoing LAM of 7-month duration with confirmed adherence, severe symptomatic hepatitis presenting with jaundice, abdominal pain, and confusion was noted. ALT 902 IU/L, HBeAg negative, HBV DNA 1.02E8 IU/mL, and genotyping confirmed L80I, M80V, and M204V/S mutations. He died 3 days after flare diagnosis despite the addition of tenofovir. Conclusion. Lamivudine should not be used for prophylaxis of patients with chronic hepatitis B with detectable HBV DNA undergoing chemotherapy with rituximab containing cytotoxic chemotherapy even if they have never had exposure to lamivudine in the past. In this setting, lamivudine failure due to resistance can develop quickly leading to liver failure that cannot be salvaged with tenofovir. Whether LAM is safe for prophylaxis with rituximab-based cytotoxic chemotherapy for patients with undetectable HBV DNA is unknown, but agents with a high barrier to resistance may be preferable. Lay Lay Win, Jeff Powis, Hemant Shah, Jordan J. Feld, and David K. Wong Copyright © 2013 Lay Lay Win et al. All rights reserved. Tocilizumab-Induced Acute Liver Injury in Adult Onset Still’s Disease Mon, 15 Jul 2013 10:54:03 +0000 Background. Tocilizumab, a monoclonal humanized anti-IL-6 receptor antibody, is used in treatment of refractory adult onset Still’s disease (AOSD). Mild to moderate liver enzyme elevation is a well-known side effect, but severe liver injury has only been reported in 3 cases in the literature. Case. A young female suffering from corticoid and methotrexate refractory AOSD was treated by tocilizumab. After 19 months of consecutive treatment, she developed acute severe liver injury. Liver biopsy showed extensive hepatocellular necrosis with ballooned hepatocytes, highly suggestive of drug-induced liver injury. No other relevant drug exposure beside tocilizumab was recorded. She recovered totally after treatment discontinuation and an initial 3-day course of intravenous N-acetylcysteine with normalization of liver function tests after 6 weeks. Conclusion. Acute severe hepatitis can be associated with tocilizumab as documented in this case. Careful monitoring of liver function tests is warranted during tocilizumab treatment. Michael Drepper, Laura Rubbia-Brandt, and Laurent Spahr Copyright © 2013 Michael Drepper et al. All rights reserved. Pleuro-Pulmonary Nocardiosis as Opportunistic Infection in a Patient with Chronic Hepatitis C under Combination Treatment with Pegylated Interferon, Ribavirin, and Boceprevir Wed, 10 Jul 2013 11:23:20 +0000 Nocardiosis is an infrequent but serious pulmonary infection caused by Gram-positive aerobic actinomycetes. In this paper, we report on a 48-year-old patient with pleuropulmonary nocardiosis and cirrhosis due to chronic hepatitis C virus infection treated with triple antiviral treatment complicated by prolonged neutropenia. Csilla Putz-Bankuti, Harald H. Kessler, Thomas Valentin, Eva Leitner, Emina Talakic, Helmut Schoellnast, Peter Fickert, Guenter J. Krejs, and Rudolf E. Stauber Copyright © 2013 Csilla Putz-Bankuti et al. All rights reserved. Hepatitis B Virus Reactivation Induced by Infliximab Administration in a Patient with Crohn’s Disease Sun, 09 Jun 2013 19:26:44 +0000 A 47-year-old man diagnosed with Crohn’s disease was treated with infliximab. He tested negative for hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (anti-HBs) but positive for anti-HB core antibody (anti-HBc). He tested positive for hepatitis B virus (HBV-) DNA 3 months after treatment and was administered entecavir. HBV-DNA test showed negative results 1 month later. ALT was persistently within the normal range, and HBV-DNA was persistently negative thereafter despite the continuation of infliximab every 8 weeks. In our hospital, 14 patients with inflammatory bowel disease, who tested negative for HBsAg, were treated with infliximab; 2 of them tested positive for anti-HBs and/or anti-HBc, and HBV reactivation was observed in 1 patient (the present patient). The present case and these findings highlight that careful follow-up is needed in patients with inflammatory bowel disease treated with infliximab who test positive for anti-HBc and/or anti-HBs. Yuka Miyake, Aki Hasebe, Tetsuya Tanihira, Akiko Shiraishi, Yusuke Imai, Haruka Tatsukawa, Hiroka Yamago, Hiromasa Nakahara, Yuko Shimizu, Keiko Ninomiya, Atsushi Hiraoka, Hideki Miyata, Tomoyuki Ninomiya, and Kojiro Michitaka Copyright © 2013 Yuka Miyake et al. All rights reserved. Drug-Induced Liver Injury Caused by Adalimumab: A Case Report and Review of the Bibliography Tue, 14 May 2013 16:24:04 +0000 The most serious adverse drug reaction of adalimumab (ADR) is tuberculosis reactivation. We describe a case of a 35-year-old man, with rheumatoid arthritis (RA) and hepatitis C virus genotype 1a with a liver biopsy in 2001 with a METAVIR score pattern A1 F0; he received interferon alpha 2b for six months, but treatment was suspended because of reactivation of RA. Liver function tests after treatment were similar to previous ones showing a minimal cholestatic pattern. In 2008, methotrexate was prescribed, but the drug was withdrawn at the third month because of the appearance of pruritus and Ggt rise. Viral load at that moment was 9300000 UI/mL, log 6,9. The liver biopsy showed a Metavir Score A2 F1. Adalimumab was started in 2010, and at the third month of treatment, Ggt showed a rise of 23 times normal value (NV), alkaline phosphatase 2,5 times NV with AST and ALT with no change. A new liver biopsy showed portal inflammation with eosinophils and a METAVIR A1 F2. We think that adalimumab appears to be responsible for the liver injury, because of temporal relationship, liver biopsy findings, other clinical conditions being discarded, and the improvement of clinical symptoms and biochemical abnormalities when adalimumab was suspended. Bernardo Frider, Andres Bruno, Marcelo Ponte, and Marcelo Amante Copyright © 2013 Bernardo Frider et al. All rights reserved. Hepatic Artery Mycotic Aneurysm Associated with Staphylococcal Endocarditis with Successful Treatment: Case Report with Review of the Literature Sun, 12 May 2013 07:58:33 +0000 Mycotic hepatic artery aneurysm is a vascular pathology associated with bacterial endocarditis. It is rare in occurrence after the introduction of effective antibiotics. We present a young patient with injection drug abuse associated staphylococcal endocarditis which was successfully treated with antibiotics and valve replacement who presented with abdominal pain. He was found to have mycotic aneurysm of hepatic artery which was successfully treated with coil embolization. Dhara Chaudhari, Atif Saleem, Pranav Patel, Sara Khan, Mark Young, and Gene LeSage Copyright © 2013 Dhara Chaudhari et al. All rights reserved. Acute Cholestatic Hepatitis A Virus Infection Presenting with Hemolytic Anemia and Renal Failure: A Case Report Wed, 08 May 2013 14:04:07 +0000 Hepatitis A virus is the most common acute viral hepatitis worldwide with approximately 1.5 million cases annually. Hepatitis A virus infection in general is self-limited. In rare cases, hepatitis A virus infection may cause renal failure, hemolytic anemia, and/or cholestasis. We report the first case of acute cholestatic hepatitis A virus infection complicated by hemolytic anemia, and renal failure in one patient. A 42-year-old Caucasian male presented with cholestasis, hemolytic anemia and renal failure after consuming street tacos in Central and South America while on a business trip. His protracted course required corticosteroid therapy, multiple sessions of plasma exchange, and numerous units of packed red blood cells. This case demonstrates the importance of vaccination in high-risk adults. A prompt diagnosis of acute hepatitis A virus infection is essential, as uncommon presentations may delay diagnosis leading to permanent morbidity and potentially death in fulminant cases. We also demonstrate the efficacy of treatment of cholestatic hepatitis A virus infection, hemolytic anemia, and renal failure with corticosteroids and plasma exchange. Robert T. Lapp and Fedja Rochling Copyright © 2013 Robert T. Lapp and Fedja Rochling. All rights reserved. Chinese Skullcap in Move Free Arthritis Supplement Causes Drug Induced Liver Injury and Pulmonary Infiltrates Sun, 14 Apr 2013 18:56:47 +0000 Herbal medications are being increasingly used by the American population especially for common conditions like arthritis. They have been reported to cause adverse effects, including significant hepatotoxicity, but reporting remains sporadic. We report here a patient who developed drug induced liver injury following the intake of Move Free, which is an over-the-counter arthritis supplement. We propose that Chinese skullcap, which is one of the herbal ingredients of the medication, is responsible for the adverse event. There was a strong temporal association between the intake of supplement and onset of symptoms, and also there have been a few recent case reports implicating the same component. A unique observation in our case is the occurrence of pulmonary infiltrates simultaneously with the hepatotoxicity, and this side effect has not been well documented before. Both the hepatic and pulmonary complications completely resolved over few weeks after the patient stopped taking the medication. Since these supplements are readily available over the counter, we feel that it is important to document possible adverse outcomes to raise awareness in the medical community and also among patients. Renumathy Dhanasekaran, Victoria Owens, and William Sanchez Copyright © 2013 Renumathy Dhanasekaran et al. All rights reserved.