Case Reports in Hepatology The latest articles from Hindawi © 2018 , Hindawi Limited . All rights reserved. Retrospective Identification of Herpes Simplex 2 Virus-Associated Acute Liver Failure in an Immunocompetent Patient Detected Using Whole Transcriptome Shotgun Sequencing Tue, 26 Dec 2017 09:57:26 +0000 Acute liver failure (ALF) is a severe condition in which liver function rapidly deteriorates in individuals without prior history of liver disease. While most cases result from acetaminophen overdose or viral hepatitis, in up to a third of patients, no clear cause can be identified. Liver transplantation has greatly reduced mortality among these patients, but 40% of patients recover without liver transplantation. Therefore, there is an urgent need for rapid determination of the etiology of acute liver failure. In this case report, we present a case of herpes simplex 2 virus- (HSV-) associated ALF in an immunocompetent patient. The patient recovered without LT, but the presence of HSV was not suspected at the time, precluding more effective treatment with acyclovir. To determine the etiology, stored blood samples were analyzed using whole transcriptome shotgun sequencing followed by mapping to a panel of viral reference sequences. The presence of HSV-DNA in blood samples at the time of admission was confirmed using real-time polymerase chain reaction, and, at the time of discharge, HSV-DNA levels had decreased by a factor of 106. Conclusions. In ALF cases of undetermined etiology, uncommon causes should be considered, especially those for which an effective treatment is available. Atsushi Ono, C. Nelson Hayes, Sakura Akamatsu, Michio Imamura, Hiroshi Aikata, and Kazuaki Chayama Copyright © 2017 Atsushi Ono et al. All rights reserved. Safety of Sofosbuvir and Ribavirin Combination Therapy in a Patient Who Developed Anemia due to Ribavirin Sun, 10 Dec 2017 07:14:02 +0000 Interferon (IFN) and ribavirin (RBV) combination therapy was previously the standard of care for treatment of hepatitis C virus (HCV) genotype 2 infection. But, it often induced hemolytic anemia. In 2014, sofosbuvir (SOF) was approved for the treatment of chronic HCV genotype 2 in Japan. SOF/RBV therapy is more effective against genotype 2 than IFN/RBV therapy. We report a case of a 74-year-old woman with chronic HCV genotype 2b infection. She received five treatments including RBV and IFN therapy before SOF was approved and all of them were ineffective. Therapies that included RBV induced severe anemia and led to discontinuation of treatment. With pegylated IFN/RBV therapy, the maximum change in hemoglobin (Hb) from baseline was −3.7 g/dL. However, SOF/RBV therapy was effective and she achieved sustained virologic response (SVR) with a maximum change in Hb from baseline of only −1.2 g/dL. We also found reticulocyte count was very low during treatment in this case and speculate it was one of the reasons that she developed hemolytic anemia with RBV. In conclusion, SOF/RBV therapy is effective and allowed the patient to achieve SVR. An SOF/RBV regimen is safe and effective for patients who have or are at risk of anemia induced by RBV. Hirokazu Suii, Itaru Ozeki, Ryoji Tatsumi, Masakatsu Yamaguchi, Mutsuumi Kimura, Tomohiro Arakawa, Tomoaki Nakajima, Yasuaki Kuwata, Takumi Ohmura, Shuhei Hige, Yoshiyasu Karino, and Joji Toyota Copyright © 2017 Hirokazu Suii et al. All rights reserved. Synthetic Cannabinoid Abuse and a Rare Alpha-1-Antitrypsin Mutant Causing Acute Fulminant Hepatitis: A Case Report and Review of the Literature Sun, 03 Dec 2017 07:24:19 +0000 Synthetic cannabinoids (SCs) abuse is on the rise because they are easily obtained over the counter; they are potent psychoactive compounds and routine drug testing does not detect them. As their abuse is on the rise, so are their detrimental side effects; however, the occurrence of acute hepatitis due to SCs abuse has been reported only once before. In this case, testing revealed that the patient was also heterozygous for alpha-1-antitrypsin (A-1-AT) with the phenotype of PIEM. This mutant phenotype has never been reported as a cause of A-1-AT disease and the abuse of SCs in a patient with this phenotype has also never been reported. This case illustrates the possible need to expand routine drug testing for SCs and consider A-1-AT phenotyping in certain clinical scenarios. Kurt J. Knowles, Eric X. Wei, Abhishek Seth, John Bienvenu, James Morris, Kenneth Manas, Paul Jordan, and Moheb Boktor Copyright © 2017 Kurt J. Knowles et al. All rights reserved. Early Onset of Tenofovir-Related Fanconi Syndrome in a Child with Acute Hepatitis B: A Case Report and Systematic Review of Literature Wed, 15 Nov 2017 00:00:00 +0000 Tenofovir disoproxil fumarate- (TDF-) related nephropathy is known to be a long-term complication of this drug, more commonly observed in HIV-infected patients, but occurring also in hepatitis B. Cases of Fanconi Syndrome associated with TDF have been reported in adult patients, usually as a long-term complication of chronic hepatitis B treatment. We present here a case of a 12-year-old male developing a severe acute HBV hepatitis treated with TDF. The patient achieved an early virological and biochemical response, but with a subsequent onset of proximal renal tubular damage, consistent with Fanconi Syndrome. After withdrawing this drug and switching to Entecavir, a complete resolution of tubulopathy and, after 6 months, a complete HBsAg seroconversion occurred. To our knowledge, this is the first report of an early renal injury due to TDF-therapy in a pediatric patient treated for acute hepatitis B. Renato Pascale, Viola Guardigni, Lorenzo Badia, Francesca Volpato, Pierluigi Viale, and Gabriella Verucchi Copyright © 2017 Renato Pascale et al. All rights reserved. Sport-Related Portal Vein Thrombosis: An Unusual Complication Sun, 12 Nov 2017 07:41:38 +0000 Portal vein thrombosis (PVT) is an uncommon condition usually associated with hypercoagulable states or liver cirrhosis. PVT due to sports-related injuries is rarely reported and, to the best of our knowledge, only two cases have been reported thus far. Brazilian jiu-jitsu (BJJ) is a form of martial arts and is considered very safe with minimal risk for injury. It has growing popularity worldwide. Here, we report the first case of PVT secondary to abdominal trauma related to the practice of (BJJ) in an otherwise healthy 32-year-old man with no other traditional risk factors for PVT. Igor Dumic, Nikola Tankosic, Milica Stojkovic Lalosevic, and Tamara Alempijevic Copyright © 2017 Igor Dumic et al. All rights reserved. Liver Metastases in Pancreatic Acinar Cell Carcinoma Treated with Selective Internal Radiation Therapy with Y-90 Resin Microspheres Wed, 11 Oct 2017 00:00:00 +0000 Background. Pancreatic acinar cell carcinoma (PACC) is a rare tumor. Surgical resection is the treatment of choice when feasible, but there are no clear recommendations for patients with advanced disease. Liver-directed therapy with Y-90 selective internal radiation therapy (SIRT) has been used to treat hepatic metastases from pancreatic tumors. We describe a case of PACC liver metastases treated with SIRT. Case Report. 59-year-old man was admitted with an infiltrative, solid lesion in pancreatic tail diagnosed as PACC. Lymph nodes in the hepatic hilum were enlarged, and many metastatic liver nodules were observed. After partial pancreatectomy, the left and right lobes of the liver were separately treated with Y-90 resin microspheres. Follow-up imaging revealed that all hepatic nodules shrank by at least 50%, and 3 nodules disappeared completely. Lipase concentration was 8407 U/L at baseline, rose to 12,705 U/L after pancreatectomy, and declined to 344 U/L after SIRT. Multiple rounds of chemotherapy in the subsequent year shrank the hepatic tumors further; disease then progressed, but a third line of chemotherapy shrank the tumors again, 16 months after SIRT treatment. Conclusion. SIRT had a positive effect on liver metastases from PACC. In conjunction with systemic therapy, SIRT can achieve sustained disease control. Felipe Nasser, Joaquim Maurício Motta Leal Filho, Breno Boueri Affonso, Francisco Leonardo Galastri, Rafael Noronha Cavalcante, Diego Lima Nava Martins, Vanderlei Segatelli, Lilian Yuri Itaya Yamaga, Rene Claudio Gansl, Bernardino Tranchesi Junior, and Antônio Luiz de Vasconcellos Macedo Copyright © 2017 Felipe Nasser et al. All rights reserved. Should Serum Protein Electrophoresis Be a Surrogate for Liver Biopsy in Some Cases of Alpha1 Antitrypsin Deficiency? Thu, 28 Sep 2017 13:28:21 +0000 Most patients with alpha1 antitrypsin deficiency do not receive this diagnosis until developing severe complications, in particular when respiratory symptoms are absent. This is a reason for making alpha1 antitrypsin deficiency a possible diagnosis among patients with cryptogenic cirrhosis or other conditions of liver disease without a clear etiology. In this report, a case of cryptogenic cirrhosis is presented, showing the role of serum protein electrophoresis in the diagnosis, which was made before liver biopsy. Therefore, the possibility of using a typical pattern of serum protein electrophoresis as a surrogate for liver biopsy in alpha1 antitrypsin deficiency is discussed. Newton Key Hokama, Marcelo Padovani de Toledo Moraes, Paula de Oliveira Montandon Hokama, and Fernando Gomes Romeiro Copyright © 2017 Newton Key Hokama et al. All rights reserved. Complete Remission after Sequential Therapy of Drug Eluting Beads Transarterial Chemoembolization and Liver Resection in Large Solitary Nodule Hepatocellular Carcinoma Wed, 27 Sep 2017 06:58:35 +0000 Hepatocellular carcinoma (HCC) is the fifth most prevalent and the second highest cause of death among cancer. The treatment of large solitary nodule HCC is still challenging. Transarterial chemoembolization (TACE) and liver resection are two modalities of therapy in HCC management. However, recurrence rate from each therapy is relatively high. We report a case of 46-year-old man diagnosed with large solitary nodule HCC, who was treated with drug eluting bead TACE (DEB-TACE) prior to liver resection. Studies about this combination are still limited and showed various results. Juferdy Kurniawan, Andri Sanityoso Sulaiman, Sahat Basana Romanti Ezer Matondang, Toar Jean Maurice Lalisang, Ening Krisnuhoni, and Steven Zulkifly Copyright © 2017 Juferdy Kurniawan et al. All rights reserved. Hemoperitoneum Secondary to Spontaneous Rupture of a Retroperitoneal Varix Thu, 03 Aug 2017 07:09:32 +0000 Hemoperitoneum due to a ruptured retroperitoneal varix is an exceedingly rare condition and a poor prognostic sign with catastrophic and life-threatening complication of portal hypertension. We present a unique case of a 56-year-old female with cirrhosis secondary to primary sclerosing cholangitis who presented with acute abdominal pain and hypovolemic shock prior to a cardiac arrest following a ruptured retroperitoneal varix without prior esophageal varices and a newly identified intrahepatic cholangiocarcinoma. The clinical presentation with abdominal pain and hemorrhagic shock is consistently reported in the relevant literature. Early recognition affords appropriate management and urgent surgical intervention leading to survival. Derrick D. Eichele Copyright © 2017 Derrick D. Eichele. All rights reserved. Herpes Simplex Virus Hepatitis: A Presentation of Multi-Institutional Cases to Promote Early Diagnosis and Management of the Disease Tue, 01 Aug 2017 08:15:25 +0000 Objective. To compare three cases of Herpes simplex virus (HSV) hepatitis to increase early diagnosis of the disease. Case1. A 23-year-old man with Crohn’s disease and oral HSV. HSV hepatitis was diagnosed clinically and he improved with acyclovir. Case2. An 18-year-old G1P0 woman with transaminitis. Despite early empiric acyclovir therapy, she died due to fulminant liver failure. Case3. A 65-year-old woman who developed transaminitis after liver transplant. Diagnosis was confirmed by biopsy and she had resolution of acute liver failure with acyclovir. Conclusion. It is imperative that clinicians be aware of patients at high risk for developing HSV hepatitis to increase timely diagnosis and prevent morbidity and fatality. Ashwinee Natu, Guiseppe Iuppa, and Clifford D. Packer Copyright © 2017 Ashwinee Natu et al. All rights reserved. Intractable Fasting Hypoglycemia as a Manifestation of Hepatocellular Carcinoma Wed, 12 Jul 2017 07:30:22 +0000 Non-islet cell tumor hypoglycemia (NICTH) is a rare and serious paraneoplastic complication of both malignant and benign tumors to consider when evaluating fasting hypoglycemia, especially in the setting of liver diseases. We present a case of NICTH in a 54-year-old male with hepatocellular carcinoma (HCC) who presented with symptomatic intractable hypoglycemia (IH) after bowel preparation and fasting for screening upper endoscopy and colonoscopy. Justin J. Forde, Ofor Ewelukwa, Tony Brar, and Roniel Cabrera Copyright © 2017 Justin J. Forde et al. All rights reserved. Tacrolimus-Induced Type IV Renal Tubular Acidosis following Liver Transplantation Thu, 06 Jul 2017 06:23:52 +0000 Calcineurin inhibitors remain an integral component of immunosuppressive therapy regimens following solid organ transplantation. Although nephrotoxicity associated with these agents is well documented, type IV renal tubular acidosis is a rare and potentially underreported complication following liver transplantation. Hepatologists must be able to recognize this adverse effect as it can lead to fatal hyperkalemia. We describe a case of tacrolimus-induced hyperkalemic type IV renal tubular acidosis in a patient following an orthotopic liver transplant for alcoholic cirrhosis. Christopher Schmoyer, Suraj Mishra, and Frank Fulco Copyright © 2017 Christopher Schmoyer et al. All rights reserved. Glycogenic Hepatopathy: Resolution with Minimal Glucose Control Wed, 26 Apr 2017 09:24:12 +0000 We describe a presentation of glycogenic hepatopathy in a poorly controlled type I diabetic patient. As patients with glycogenic hepatopathy often have nonspecific complaints, diagnosis tends to be delayed and laboratory and imaging data are often indistinguishable from nonalcoholic fatty liver disease. Our patient’s diagnosis of glycogenic hepatopathy required a liver biopsy, which demonstrated the characteristic pathology. Her symptoms resolved with minimal alteration to her insulin regimen and only slightly improved glucose control. Abhimanyu Chandel, Brittany Scarpato, Jeanette Camacho, Miles McFarland, and Shaffer Mok Copyright © 2017 Abhimanyu Chandel et al. All rights reserved. Severe Aplastic Anemia following Parvovirus B19-Associated Acute Hepatitis Thu, 20 Apr 2017 09:07:49 +0000 Human parvovirus (HPV) B19 is linked to a variety of clinical manifestations, such as erythema infectiosum, nonimmune hydrops fetalis, and transient aplastic anemia. Although a few cases have shown HPVB19 infection as a possible causative agent for hepatitis-associated aplastic anemia (HAAA) in immunocompetent patients, most reported cases of HAAA following transient hepatitis did not have delayed remission. Here we report a rare case of severe aplastic anemia following acute hepatitis with prolonged jaundice due to HPVB19 infection in a previously healthy young male. Clinical laboratory examination assessed marked liver injury and jaundice as well as peripheral pancytopenia, and bone marrow biopsy revealed severe hypoplasia and fatty replacement. HPVB19 infection was diagnosed by enzyme immunoassay with high titer of anti-HPVB19 immunoglobulin M antibodies. Immunosuppressive therapy was initiated 2 months after the onset of acute hepatitis when liver injury and jaundice were improved. Cyclosporine provided partial remission after 2 months of medication without bone marrow transplantation. Our case suggests that HPVB19 should be considered as a hepatotropic virus and a cause of acquired aplastic anemia, including HAAA. Masanori Furukawa, Kosuke Kaji, Hiroyuki Masuda, Kuniaki Ozaki, Shohei Asada, Aritoshi Koizumi, Takuya Kubo, Norihisa Nishimura, Yasuhiko Sawada, Kosuke Takeda, Tsuyoshi Mashitani, Masayuki Kubo, Itsuto Amano, Tomoyuki Ootani, Chiho Ohbayashi, Koji Murata, Tatsuichi Ann, Akira Mitoro, and Hitoshi Yoshiji Copyright © 2017 Masanori Furukawa et al. All rights reserved. Severe Acute Hepatitis B in HBV-Vaccinated Partner of a Patient with Multiple Myeloma Treated with Cyclophosphamide, Bortezomib, and Dexamethasone and Autologous Stem Cell Transplant Mon, 27 Mar 2017 06:24:41 +0000 Hepatitis B reactivation can occur with various forms of immunosuppression. Cyclophosphamide, Bortezomib, and Dexamethasone (CYBOR-D) chemotherapy is commonly used for the treatment of multiple myeloma and has not been noted in guidelines to be causative in HBV reactivation. Indeed, current guidelines do not recommend providing antiviral prophylaxis to patients with prior HBV infection. We present a case of HBV reactivation as a result of CYBOR-D and autologous stem cell transplant which is complicated by the patient’s partner who developed acute hepatitis B. Our case highlights the need to review the role of antiviral prophylaxis for patients undergoing treatment of multiple myeloma and also the role of ensuring immunity for close contacts of these patients who may also be at risk. Majed M. Almaghrabi, Kyle J. Fortinsky, and David Wong Copyright © 2017 Majed M. Almaghrabi et al. All rights reserved. Cervical Spinal Cord Compression: A Rare Presentation of Hepatocellular Carcinoma Thu, 09 Feb 2017 00:00:00 +0000 Hepatocellular carcinoma (HCC) is the most common primary malignancy of liver. Distant metastasis to various organs is well known. Skeletal metastasis is also reported to various locations. Vertebral metastasis has been reported mostly to thoracic spine. However, cervical spinal cord involvement leading to cord compression has been reported very rarely in literature. We present a case of 58-year-old male with liver cirrhosis presenting as neck pain. Further work-up revealed metastatic HCC to cervical spinal cord resulting in acute cord compression. Patient has been treated with neurosurgical intervention. Puvanalingam Ayyadurai, Kanthi Rekha Badipatla, Chukwunonso Chime, Shiva Arjun, Pavithra Reddy, Masooma Niazi, and Suresh Kumar Nayudu Copyright © 2017 Puvanalingam Ayyadurai et al. All rights reserved. Diphenhydramine as a Cause of Drug-Induced Liver Injury Thu, 26 Jan 2017 07:53:12 +0000 Drug-induced liver injury (DILI) is the most common cause of acute liver failure in the Unites States and accounts for 10% of acute hepatitis cases. We report the only known case of diphenhydramine-induced acute liver injury in the absence of concomitant medications. A 28-year-old man with history of 13/14-chromosomal translocation presented with fevers, vomiting, and jaundice. Aspartate-aminotransferase and alanine-aminotransferase levels peaked above 20,000 IU/L and 5,000 IU/L, respectively. He developed coagulopathy but without altered mental status. Patient reported taking up to 400 mg diphenhydramine nightly, without concomitant acetaminophen, for insomnia. He denied taking other medications, supplements, antibiotics, and herbals. A thorough workup of liver injury ruled out viral hepatitis (including A, B, C, and E), autoimmune, toxic, ischemic, and metabolic etiologies including Wilson’s disease. A liver biopsy was consistent with DILI without evidence of iron or copper deposition. Diphenhydramine was determined to be the likely culprit. This is the first reported case of diphenhydramine-induced liver injury without concomitant use of acetaminophen. Yunseok Namn, Yecheskel Schneider, Isabelle H. Cui, and Arun Jesudian Copyright © 2017 Yunseok Namn et al. All rights reserved. Viekira Pak Induced Fatal Lactic Acidosis: A Case Report of an Unusual Side Effect Thu, 01 Dec 2016 10:37:15 +0000 Viekira Pak is a new direct-acting antiviral agent that has an excellent efficacy in treating patients with chronic HCV. FDA released a safety warning that Viekira Pak can cause serious liver injury mostly in patients with underlying advanced liver disease. We report the first case of fatal lactic acidosis presenting 3 days after initiating therapy with Viekira Pak. Although it is very hard to precisely determine the cause of lactic acidosis, our case highlights an unusual side effect that ensued after starting the medication. Given the complexity of drug-drug interactions that can happen with the new direct-acting antiviral agents and the paucity of data regarding coadministration and methods of monitoring, a thorough review should be pursued prior to initiating these medications. Molham Abdulsamad and Ariyo Ihimoyan Copyright © 2016 Molham Abdulsamad and Ariyo Ihimoyan. All rights reserved. Severe Anemia with Hemoperitoneum as a First Presentation for Multinodular Hepatocellular Carcinoma: A Rare Event in Western Countries Wed, 23 Nov 2016 14:18:50 +0000 Hemoperitoneum due to spontaneous rupture of hepatocellular carcinoma is a life-threatening and rare condition in western countries with an incidence of less than 3% because of early detection of cirrhosis and neoplasm. Here, we describe a case of a 66-year-old male patient with altered mental status with hemorrhagic shock. Computed tomography scan of abdomen revealed hemoperitoneum and mass in liver. Patient underwent resection of liver tumor and biopsy revealed multinodular hepatocellular carcinoma. A high degree of suspicion is required where severe anemia and hemoperitoneum can be a first presentation for hepatocellular carcinoma especially in patients with chronic hepatitis C infection. Early diagnosis is crucial since mortality rates remain high for untreated cases. Thein Swe, Akari Thein Naing, Aama Baqui, and Ratesh Khillan Copyright © 2016 Thein Swe et al. All rights reserved. Herpes Simplex Virus Hepatitis in an Immunocompetent Host Resembling Hepatic Pyogenic Abscesses Sun, 30 Oct 2016 11:20:44 +0000 Herpes simplex virus (HSV) hepatitis represents a rare complication of HSV infection, which can progress to acute liver failure and, in some cases, death. We describe an immunocompetent 67-year-old male who presented with one week of fever and abdominal pain. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the abdomen showed multiple bilobar hepatic lesions, some with rim enhancement, compatible with liver abscesses. Subsequent liver biopsy, however, revealed hepatocellular necrosis, HSV-type intranuclear inclusions, and immunostaining positive for herpes virus type 2 (HSV-2). Though initially treated with broad-spectrum antibiotics, following histologic diagnosis of HSV hepatitis, the patient was transitioned to intravenous acyclovir for four weeks and he achieved full clinical recovery. Given its high mortality and nonspecific presentation, one should consider HSV hepatitis in all patients with acute hepatitis with multifocal hepatic lesions of unknown etiology. Of special note, this is only the second reported case of HSV liver lesions mimicking pyogenic abscesses on CT and MRI. Carrie Down, Amit Mehta, Gayle Salama, Erika Hissong, Russell Rosenblatt, Michael Cantor, David Helfgott, and Kristen Marks Copyright © 2016 Carrie Down et al. All rights reserved. Hepatocellular Carcinoma with Prominent Intracytoplasmic Inclusions: A Report of Two Cases Wed, 12 Oct 2016 14:23:58 +0000 Hepatocellular carcinoma (HCC) is the commonest primary malignant neoplasm of the liver in most countries with a notoriously poor prognosis. Variation in global incidence is well-recognized and the occurrence of HCC is linked to several established environmental, dietary, and lifestyle factors. HCC demonstrates morphological heterogeneity both within the same tumor and from patient to patient. Differing architectural patterns and cytological variants may be seen. Inclusion bodies are believed to represent organized structures of proteins which contribute to their pathogenesis and share several constituents like chaperones, p62, ubiquitin, and Valosin containing protein. The various hepatocyte cytoplasmic inclusions described in HCC include Mallory-Denk bodies (MDBs), hyaline bodies (HBs), glycogen, fat, fibrinogen, alpha 1 antitrypsin (AAT), and ground glass. MDBs are the most common inclusions seen in hepatocellular carcinomas. The two cases shared intracytoplasmic inclusions which are characterized by larger sizes and present in every section examined. These exhibited features of MDBs and HBs present in most tumor cells, further supporting close relationship. Adeline R. Chelliah and Jasim M. Radhi Copyright © 2016 Adeline R. Chelliah and Jasim M. Radhi. All rights reserved. Fulminant Hepatic Failure in a Patient with Crohn’s Disease on Infliximab Possibly Related to Reactivation of Herpes Simplex Virus 2 Infection Wed, 12 Oct 2016 11:06:20 +0000 HSV hepatitis is a rare but often fatal cause of liver failure which tends to affect immunocompromised individuals. Early treatment with Acyclovir has been shown to reduce mortality in HSV hepatitis making recognition of the condition critically important. Here, we present a case of HSV hepatitis in a young woman with Crohn’s disease on Prednisone, Azathioprine, and Infliximab. We discuss the clinical presentation of HSV hepatitis as well as the possible causes of hepatitis in a patient on these medications. This case helps demonstrate the importance of early clinical suspicion for HSV in undifferentiated fulminate liver failure. It is also the first reported case of HSV hepatitis in a patient on Infliximab, raising the possibility of HSV reactivation in patients on Infliximab. Gary Golds and Lawrence Worobetz Copyright © 2016 Gary Golds and Lawrence Worobetz. All rights reserved. Progression of Hepatic Adenoma to Carcinoma in the Setting of Hepatoportal Sclerosis in HIV Patient: Case Report and Review of the Literature Wed, 12 Oct 2016 08:23:37 +0000 We report a case of hepatic adenoma progression to carcinoma in the setting of hepatoportal sclerosis in an HIV+ patient and provide a review of the scarce literature regarding hepatoportal sclerosis in HIV patients. We describe the clinical presentation, diagnostic workup, and management. This is the first case report in the literature of progression of hepatic adenoma to carcinoma in hepatoportal sclerosis in an HIV patient. This case also highlights the broad differential diagnosis that should always be included in the study of any liver disease in this patient population, including the performance of invasive and aggressive tests to arrive at the final diagnosis. M. I. Montenovo, F. G. Jalikis, M. Yeh, and J. D. Reyes Copyright © 2016 M. I. Montenovo et al. All rights reserved. Enteroscopic Management of Ectopic Varices in a Patient with Liver Cirrhosis and Portal Hypertension Wed, 10 Aug 2016 11:15:28 +0000 Portal hypertension and liver cirrhosis may predispose patients to varices, which have a propensity to bleed and cause significant morbidity and mortality. These varices are most commonly located in the gastroesophageal area; however, rarely ectopic varices may develop in unusual locations outside of this region. Haemorrhage from these sites can be massive and difficult to control; thus early detection and management may be lifesaving. We present a case of occult gastrointestinal bleeding in a patient with underlying alcoholic liver disease where an ectopic varix was ultimately detected with push enteroscopy. G. A. Watson, A. Abu-Shanab, R. L. O’Donohoe, and M. Iqbal Copyright © 2016 G. A. Watson et al. All rights reserved. Tumor Regression in HCC Patient with Portal Vein Tumor Thrombosis after Intraportal Radiofrequency Thermal Ablation Mon, 08 Aug 2016 13:23:52 +0000 Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death worldwide. Portal vein tumor thrombosis (PVTT) is a frequent entity in HCC, which strictly limits the gold standard treatment options such as surgical resection and transarterial chemoembolization. Therefore, the prognosis of patients with PVTT is extremely poor and an emergence of seeking an alternative option for intervention is inevitable. We present a case of a 60-year-old male patient with HCC induced PVTT who was subjected to the intraportal RFA and stenting-VesOpen procedure. No additional medical intervention was performed. The repeated CT performed 5 months after the VesOpen procedure revealed significant decrease of the tumor size, patent right, and main portal vein and a recanalization of the left portal vein, which was not processed. At this time point, liver functional tests, appetite, and general condition of the patient were improved evidently. This report designates the RFA as an instrumental option of therapeutic intervention for HCC patients with PVTT. Malkhaz Mizandari, Tamta Azrumelashvili, Natela Paksashvili, Nino Kikodze, Ia Pantsulaia, Nona Janikashvili, and Tinatin Chikovani Copyright © 2016 Malkhaz Mizandari et al. All rights reserved. Melioidosis: A Rare Cause of Liver Abscess Tue, 26 Jul 2016 09:15:43 +0000 Case Presentation. This is a case of a 44-year-old male, farmer, known to be diabetic, presenting with two-week history of vague abdominal pain associated with high grade fever. Abdominal CT scan showed localized liver abscess at segment 8 measuring 7.5 × 6.8 × 6.1 cm. Patient subsequently underwent laparoscopic ultrasound guided pigtail insertion for drainage of abscess. Culture studies showed moderate growth of Burkholderia pseudomallei in which the patient completed seven days of IV Meropenem. On follow-up after 12 weeks of oral Sulfamethoxazole/Trimethoprim, taken twice a day, the patient remained asymptomatic with no residual findings based on the abdominal ultrasound. Discussion. Diagnosis of melioidosis, a known “great masquerader,” relies heavily on culture studies. Consensus with regard to the management of liver abscess caused by Burkholderia pseudomallei has not yet been established due to the rarity of cases. Surgical intervention through either a percutaneous or open drainage has shown good outcomes compared to IV antibiotics alone. In Philippines, the possibility of underreporting is highly plausible. This write-up serves not only to report a rare presentation of melioidosis but also to add to the number of cases reported in the country, possibly indicative of disease emergence. Peter Franz M. San Martin, Catherine S. C. Teh, and Ma. Amornetta J. Casupang Copyright © 2016 Peter Franz M. San Martin et al. All rights reserved. Budd-Chiari Syndrome in a Patient with Hepatitis C Wed, 20 Jul 2016 16:46:09 +0000 Chronic Budd-Chiari syndrome can present with cirrhosis and signs and symptoms similar to those of other chronic liver diseases. We present a case of Budd-Chiari syndrome discovered during attempted transjugular intrahepatic portosystemic shunting in a patient with decompensated cirrhosis believed to be secondary to hepatitis C. Although the patient had hepatocellular carcinoma, the Budd-Chiari syndrome was a primary disease due to hepatic venous webs. Angioplasty was performed in this case, which resolved the patient’s symptoms related to portal hypertension. Follow-up venography 5 months after angioplasty demonstrated continued patency of the hepatic veins. A biopsy was obtained in the same setting, which showed centrilobular fibrosis indicating that venous occlusion was indeed the cause of cirrhosis. It is important to consider a second disease when treating a patient with difficult to manage portal hypertension. Joseph Frankl, Charles Hennemeyer, Michael S. Flores, and Archita P. Desai Copyright © 2016 Joseph Frankl et al. All rights reserved. Angiomyolipoma in a Patient with Situs Inversus Totalis: Managing Two Rare Diseases Wed, 20 Jul 2016 13:23:58 +0000 Hepatic angiomyolipoma is an extremely rare benign hamartomatous lesion. Situs inversus totalis is a genetic condition occurring in 0.01% of the population. Following the kidney, the liver is the second most common site of angiomyolipoma. No consensus on the treatment of hepatic angiomyolipoma has been reached. However, the majority of these tumours are managed conservatively. Situs inversus totalis presents difficulties for procedures and is most commonly an incidental finding. These two conditions have not previously been reported and no genetic link has been established between them. This paper reports the association of both conditions in a 74-year-old female, reviews the literature, and presents CT imaging of the case. Jonathan Mayes and Nigel Heaton Copyright © 2016 Jonathan Mayes and Nigel Heaton. All rights reserved. Hepatotoxicity due to Clindamycin in Combination with Acetaminophen in a 62-Year-Old African American Female: A Case Report and Review of the Literature Mon, 04 Jul 2016 10:12:22 +0000 Clindamycin is a bacteriostatic lincosamide antibiotic with a broad spectrum. Side effects include nausea, vomiting, diarrhea, and metallic taste; however, hepatotoxicity is rare. The incidence is unknown. It is characterized by increases in aspartate and alanine transaminases. There may be no symptoms and the treatment is to stop the administration of clindamycin. We have described a 62-year-old African American female medicated with acetaminophen and clindamycin who had initially presented to the dental clinic for the evaluation of gum pain following tooth extraction. She had significantly increased levels of liver transaminases, which trended downwards on quitting the medication. Jerome Okudo and Nwabundo Anusim Copyright © 2016 Jerome Okudo and Nwabundo Anusim. All rights reserved. Clopidogrel-Induced Severe Hepatitis: A Case Report and Literature Review Mon, 27 Jun 2016 10:28:11 +0000 Clopidogrel is a commonly prescribed antiplatelet agent that carries a rare risk of hepatotoxicity. We describe a case of severe clopidogrel-induced hepatitis with liver biopsy assessment. Prompt recognition and withdrawal of the offending agent are imperative to prevent progression and potentially fatal liver injury. Hesam Keshmiri, Anuj Behal, Shawn Shroff, and Charles Berkelhammer Copyright © 2016 Hesam Keshmiri et al. All rights reserved.