Case Reports in Hepatology The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Markedly Improved Glycemic Control in Poorly Controlled Type 2 Diabetes following Direct Acting Antiviral Treatment of Genotype 1 Hepatitis C Tue, 17 May 2016 12:58:26 +0000 Type 2 diabetes mellitus (T2DM) is often associated with hepatitis C virus (HCV) infection. Successful HCV treatment may improve glycemic control and potentially induce remission of T2DM. We report a case of an obese 52-year-old woman with mixed genotype 1a/1b HCV infection with compensated cirrhosis and a 10-year history of poorly controlled T2DM on insulin therapy. Following successful therapy with sofosbuvir, simeprevir, and ribavirin, her insulin requirements decreased and her glycosylated hemoglobin (HgA1c) normalized despite weight gain. This case suggests an association between HCV and T2DM and the potential for significant improvement in glycemic control with eradication of HCV. Raymond Anthony Pashun, Nicole T. Shen, and Arun Jesudian Copyright © 2016 Raymond Anthony Pashun et al. All rights reserved. Antihistamine-Induced Hepatitis: 2 Cases Involving Loratidine Sun, 15 May 2016 11:21:30 +0000 Antihistamine-induced hepatitis is rare. We present 2 cases of antihistamine-induced hepatitis with autoimmune features, caused by loratidine. One case was confirmed by rechallenge. Identifying and discontinuing the offending agent are essential for treatment. Hafiz Arshad, Arsalan Khan, Usama Assad, Muaiad Kittaneh, and Charles Berkelhammer Copyright © 2016 Hafiz Arshad et al. All rights reserved. Gallbladder Tuberculosis Mimicking Gallbladder Carcinoma: A Case Report and Literature Review Thu, 21 Apr 2016 12:25:50 +0000 Gallbladder tuberculosis (GT) is extremely rare, and it is difficult to differentiate from other gallbladder diseases, such as gallbladder carcinoma and Xanthogranulomatous Cholecystitis. A correct preoperative diagnosis of GT is difficult. The final diagnosis is usually made postoperatively according to surgical biopsy. Here, we report a case of a patient who underwent surgery with the preoperative diagnosis of gallbladder carcinoma. We reviewed the literature and present the process of differential diagnosis between two or more conditions that share similar signs or symptoms. Yao Liu, Kai Wang, and Heng Liu Copyright © 2016 Yao Liu et al. All rights reserved. Acute Hepatitis after Ingestion of a Preparation of Chinese Skullcap and Black Catechu for Joint Pain Sun, 10 Apr 2016 15:56:05 +0000 Many herbal preparations are routinely used and have been occasionally associated with a wide range of side effects, from mild to severe. Chinese skullcap and black catechu are herbal medications commonly used for their hepatoprotective and other properties. We report a case of acute toxic hepatitis associated with ingestion of Chinese skullcap and black catechu in one preparation for the alleviation of joint pain. Charilaos Papafragkakis, Mel A. Ona, Madhavi Reddy, and Sury Anand Copyright © 2016 Charilaos Papafragkakis et al. All rights reserved. Laparoscopic Resection of Cholecystocolic Fistula and Subtotal Cholecystectomy by Tri-Staple in a Type V Mirizzi Syndrome Sun, 24 Jan 2016 07:20:10 +0000 The Mirizzi syndrome (MS) is an impacted stone in the cystic duct or Hartmann’s pouch that mechanically obstructs the common bile duct (CBD). We would like to report laparoscopic subtotal cholecystectomy (SC) and resection of cholecystocolic fistula by the help of Tri-Staple™ in a case with type V MS and cholecystocolic fistula, for first time in the literature. A 24-year-old man was admitted to emergency department with the complaint of abdominal pain, intermittent fever, jaundice, and diarrhea. Two months ago with the same complaint, ERCP was performed. Laparoscopic resection of cholecystocolic fistula and subtotal cholecystectomy were performed by the help of Tri-Staple. At the eight-month follow-up, he was symptom-free with normal liver function tests. In a patient with type V MS and cholecystocolic fistula, laparoscopic resection of cholecystocolic fistula and SC can be performed by using Tri-Staple safely. Fahri Yetişir, Akgün Ebru Şarer, Hasan Zafer Acar, Omer Parlak, Basar Basaran, and Omer Yazıcıoğlu Copyright © 2016 Fahri Yetişir et al. All rights reserved. Another Report of Acalculous Cholecystitis in a Greek Patient with Infectious Mononucleosis: A Matter of Luck or Genetic Predisposition? Thu, 14 Jan 2016 14:10:41 +0000 We here report a case of a young, male patient who presented with jaundice and was diagnosed with acalculous cholecystitis during the course of a primary Epstein-Barr Virus (EBV) infection. The coexistence of cholestatic hepatitis and acalculous cholecystitis in patients with infectious mononucleosis is extremely uncommon and only few cases can be found in the literature. Moreover, almost one-fourth of the total reports of this rare entity are coming from Greece. Whether this is a result of physicians’ high index of suspicion due to previous reports or a consequence of genetic predisposition is an issue that deserves further investigation in the future. More studies are required in order to clarify the pathophysiological and genetic backgrounds that connect acalculous cholecystitis and EBV infection. Theocharis Koufakis and Ioannis Gabranis Copyright © 2016 Theocharis Koufakis and Ioannis Gabranis. All rights reserved. Onset of Celiac Disease after Treatment of Chronic Hepatitis C with Interferon Based Triple Therapy Wed, 18 Nov 2015 11:43:39 +0000 Background. Patients treated with interferon (IFN) based therapies may develop exacerbation of autoimmune disease. We herein present the case of a 53-year-old female patient who developed celiac disease (CD) as a result of triple therapy (interferon, ribavirin, and boceprevir) for chronic HCV. Case. 53-year-old Caucasian female with past medical history of IV drug abuse was referred for abnormal LFTs. Laboratory data showed HCV RNA of 4,515,392 IU/mL, HCV genotype 1a, with normal LFTs. She was treated with 4 weeks of pegylated interferon alfa-2a plus ribavirin, followed by triple therapy using boceprevir for a total of 28 weeks. Approximately 4 weeks after initiation of triple therapy patient developed loose nonbloody bowel movements and was also found to have anemia. Biopsies from first and second portions of the duodenum were consistent with CD. The patient was treated with a gluten-free diet. Her intestinal symptoms improved and the hemoglobin returned to normal. Conclusion. Chronic HCV patients being treated with interferon alfa can develop celiac disease during or after therapy. For patients with positive autoantibodies, all-oral-IFN-free regimens should be considered. Celiac disease should be considered in patients who develop CD-like symptoms while on and shortly after cessation of interferon alfa therapy. Amandeep Singh, Nayere Zaeri, and Immanuel K. Ho Copyright © 2015 Amandeep Singh et al. All rights reserved. Glycogenic Hepatopathy in Type 1 Diabetes Mellitus Mon, 10 Aug 2015 11:48:05 +0000 Glycogenic hepatopathy is a rare cause of high transaminase levels in type 1 diabetes mellitus. This condition, characterized by elevated liver enzymes and hepatomegaly, is caused by irreversible and excessive accumulation of glycogen in hepatocytes. This is a case report on a 19-year-old male case, diagnosed with glycogenic hepatopathy. After the diagnosis was documented by liver biopsy, the case was put on glycemic control which led to significant decline in hepatomegaly and liver enzymes. It was emphasized that, in type 1 diabetes mellitus cases, hepatopathy should also be considered in the differential diagnoses of elevated liver enzyme and hepatomegaly. Murat Atmaca, Rifki Ucler, Mehmet Kartal, Ismet Seven, Murat Alay, Irfan Bayram, and Sehmus Olmez Copyright © 2015 Murat Atmaca et al. All rights reserved. Disseminated Herpes Simplex Virus with Fulminant Hepatitis Tue, 28 Jul 2015 11:32:41 +0000 Disseminated herpes simplex virus (HSV) is a rare cause of acute fulminant liver failure. We hereby present a case series of three patients with acute disseminated HSV with necrotizing hepatitis successfully treated with a week course of acyclovir. Early empiric administration of acyclovir therapy while awaiting confirmatory tests is critical in this potentially lethal disease. Bassam H. Rimawi, Joseph Meserve, Ramzy H. Rimawi, Zaw Min, and John W. Gnann Jr. Copyright © 2015 Bassam H. Rimawi et al. All rights reserved. Linoleic Acid Induced Acute Hepatitis: A Case Report and Review of the Literature Thu, 09 Jul 2015 11:10:12 +0000 Several dietary supplements used for weight loss have been reported to cause hepatotoxicity. Conjugated Linoleic Acid (CLA) is a dietary supplement that has been shown to cause reduction in body fat mass. Here, we present the first case of CLA induced acute hepatitis in the United States and only the third case in the worldwide literature along with a brief review of the literature. Mohammad Bilal, Yogesh Patel, Micheal Burkitt, and Michael Babich Copyright © 2015 Mohammad Bilal et al. All rights reserved. Sickle Cell Trait Causing Splanchnic Venous Thrombosis Mon, 29 Jun 2015 08:08:39 +0000 Sickle cell trait is considered as a benign condition as these individuals carry only one defective gene and typically have their life span similar to the normal population without any health problems related to sickle cell. Only under extreme conditions, red cells become sickled and can cause clinical complications including hematuria and splenic infarction. Although twofold increased risk of venous thrombosis has been described in African Americans, there is no data available from Indian population. We here report a case of sickle cell trait from India whose index presentation was thrombosis of unusual vascular territory. Priyanka Saxena, Pratibha Dhiman, Chhagan Bihari, and Archana Rastogi Copyright © 2015 Priyanka Saxena et al. All rights reserved. Acute Liver Toxicity due to Efavirenz/Emtricitabine/Tenofovir Tue, 16 Jun 2015 12:15:20 +0000 The fixed-dose combination of Efavirenz/Emtricitabine/Tenofovir is a first-line agent for the treatment of HIV; however few cases have reported hepatotoxicity associated with the drug. We report a case of Efavirenz/Emtricitabine/Tenofovir-associated hepatotoxicity presenting mainly with hepatocellular injury characterized by extremely elevated aminotransferase levels, which resolved without acute liver failure or need for liver transplant referral. Rashmee Patil, Mel A. Ona, Haris Papafragkakis, Jeanne Carey, Yitzchak Moshenyat, Adib Alhaddad, and Sury Anand Copyright © 2015 Rashmee Patil et al. All rights reserved. Enterococcus gallinarum Spontaneous Bacterial Peritonitis in an HCV Cirrhotic Thu, 07 May 2015 09:59:29 +0000 We present the case of a 60-year-old Caucasian male with history of hepatitis C viral cirrhosis with portosystemic encephalopathy and ascites with evidence of spontaneous bacterial peritonitis (SBP) with absolute neutrophil count (ANC) of 944 cells/µL blood. Despite adequate treatment, the abdominal pain and elevated creatinine continued to persist. Initial ascites fluid cultures returned back positive for growth of Enterococcus gallinarum. Empiric antibiotics were then substituted with ampicillin/sulbactam. Our case of Enterococcus gallinarum causing SBP is only the seventh case reported in the literature to date. Hussein Abidali, Maheen Sheikh, Moustapha Abidali, Ali Abidali, Hamoudi S. Farraji, and Andrew C. Berry Copyright © 2015 Hussein Abidali et al. 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.