[Infantile cholestasis caused by CFTR mutation: case report and literature review]

Objective: To study the clinical presentation, biochemical features and genetic analysis of an infant with cholestasis related to the CFTR mutations. Method: The clinical presentation, laboratory investigations and management of a case with infantile cholestasis caused by CFTR mutations were summarized and the relevant literature was reviewed. Result: (1) The patient was a 5 months old boy with cholestasis which developed in neonatal period with delayed meconium exclusion.The laparoscopic exploration was performed to exclude biliary atresia because of acholic stool when he was two months old.Ursodeoxycholic acid (UDCA), cholestyramine and phenobarbital treatment was applied.The genetic analysis showed compound heterozygous mutations in CFTR. The liver function normalized when he was 11 months old.When he was 21 months old, he had normal appearance except mild splenomegaly.(2) Literatures review identified 25 infantile cholestatic cases related to cystic fibrosis (CF) diagnosed by sweat test or gene analysis.Delayed meconium passage was found in five, meconium ileus in six cases.The liver function tests characterized by the direct hyperbilirubinemia with elevated transaminase, glutamyltranspeptidase and alkaline phosphatase levels.Genetic analysis revealed eight homozygotes of delF508, four heterozygotes of delF508 and one compound heterozygotes of c. 263T>G/ c. 2089-2090ins in CFTR.Jaundice resolved in 20 patients, ten of them were prescribed oral ursodesoxycholic acid (15-20 mg/(kg·d)). Five patients died, none of them received oral UDCA.Two of them had persisted cholestatic until death. Among the other three dead, two died from respiratory failure and one from cardiopulmonary failure. Conclusion: Cystic fibrosis should be considered in cholestatic infants with meconium ileus or delayed meconium passage.Genetic analysis could confirm the diagnosis.UDCA may be beneficial to improve the liver function.

Optimising case detection within UK electronic health records: use of multiple linked databases for detecting liver injury

OBJECTIVES

We aimed to create a 'multidatabase' algorithm for identification of cholestatic liver injury using multiple linked UK databases, before (1) assessing the improvement in case ascertainment compared to using a single database and (2) developing a new single-database case-definition algorithm, validated against the multidatabase algorithm.

DESIGN

Method development for case ascertainment.

SETTING

Three UK population-based electronic health record databases: the UK Clinical Practice Research Datalink (CPRD), the UK Hospital Episodes Statistics (HES) database and the UK Office of National Statistics (ONS) mortality database.

PARTICIPANTS

16 040 people over the age of 18 years with linked CPRD-HES records indicating potential cholestatic liver injury between 1 January 2000 and 1 January 2013.

PRIMARY OUTCOME MEASURES

(1) The number of cases of cholestatic liver injury detected by the multidatabase algorithm. (2) The relative contribution of each data source to multidatabase case status. (3) The ability of the new single-database algorithm to discriminate multidatabase algorithm case status.

RESULTS

Within the multidatabase case identification algorithm, 4033 of 16 040 potential cases (25%) were identified as definite cases based on CPRD data. HES data allowed possible cases to be discriminated from unlikely cases (947 of 16 040, 6%), but only facilitated identification of 1 definite case. ONS data did not contribute to case definition. The new single-database (CPRD-only) algorithm had a very good ability to discriminate multidatabase case status (area under the receiver operator characteristic curve 0.95).

CONCLUSIONS

CPRD-HES-ONS linkage confers minimal improvement in cholestatic liver injury case ascertainment compared to using CPRD data alone, and a multidatabase algorithm provides little additional information for validation of a CPRD-only algorithm. The availability of laboratory test results within CPRD but not HES means that algorithms based on CPRD-HES-linked data may not always be merited for studies of liver injury, or for other outcomes relying primarily on laboratory test results.

Amoxicillin-Clavulanate-Induced Liver Injury

BACKGROUND AND AIMS

Amoxicillin-clavulanate (AC) is the most frequent cause of idiosyncratic drug-induced injury (DILI) in the US DILI Network (DILIN) registry. Here, we examined a large cohort of AC-DILI cases and compared features of AC-DILI to those of other drugs.

METHODS

Subjects with suspected DILI were enrolled prospectively, and cases were adjudicated as previously described. Clinical variables and outcomes of patients with AC-DILI were compared to the overall DILIN cohort and to DILI caused by other antimicrobials.

RESULTS

One hundred and seventeen subjects with AC-DILI were identified from the cohort (n = 1038) representing 11 % of all cases and 24 % of those due to antimicrobial agents (n = 479). Those with AC-DILI were older (60 vs. 48 years, P < 0.001). AC-DILI was more frequent in men than women (62 vs. 39 %) compared to the overall cohort (40 vs. 60 %, P < 0.001). The mean time to symptom onset was 31 days. The Tb, ALT, and ALP were 7 mg/dL, 478, and 325 U/L at onset. Nearly all liver biopsies showed prominent cholestatic features. Resolution of AC-DILI, defined by return of Tb to <2.5 mg/dL, occurred on average 55 days after the peak value. Three female subjects required liver transplantation, and none died due to DILI.

CONCLUSION

AC-DILI causes a moderately severe, mixed hepatocellular-cholestatic injury, particularly in older men, unlike DILI in general, which predominates in women. Although often protracted, eventual apparent recovery is typical, particularly for men and usually in women, but three women required liver transplantation.

Myeloid Sarcoma of the Hepatobiliary System: A Case Series and Review of the Literature

Myeloid sarcoma (MS) is a rare extramedullary presentation of myeloid malignancies, most commonly seen in association with acute myeloid leukemia (AML). Although MS can develop in any organ, the involvement of the hepatobiliary system is rare. With clinical manifestations of jaundice, abdominal pain and other gastrointestinal symptoms, MS presenting at this location can be a challenge to diagnose, particularly in patients with no known history of hematologic malignancy. This may cause delay in proper management. Here we report 3 cases from a single institution and a review of the literature concerning the epidemiology, clinical presentation, treatment and outcomes in patients with MS of the liver, biliary tree and pancreas.

Hereditary Spherocytosis with Splenomegaly and Cholelithiasis in a Young Male of Western Region of Nepal - A Case Report

Hereditary spherocytosis is an autosomal dominant congenital hemolytic anemia due to defect in RBC membrane protein that commonly presents with intermittent jaundice, anemia, abdominal pain, splenomegaly and sometimes cholelithiasis. Due to the membrane defect, there is increased fragility, hemolytic anemia, marked splenomegaly and hyperbilirubinemia. This is a report of an 11 years old male diagnosed case of hereditary spherocytosis who presented with jaundice, splenomegaly and cholelithiasis. He underwent elective open splenectomy and cholecystectomy after prophylactic immunization for capsulated organisms and was advised lifelong oral penicillin prophylaxis post-splenectomy.

Placement of a duodenal stents bridge the duodenal papilla may predispose to acute pancreatitis

BACKGROUND/AIMS

To retrospective evaluate the incidence, predictive factors, and management of acute pancreatitis after placement of duodenal stent in patients with malignant gastroduodenal obstruction.

METHODOLOGY

Among 242 patients with symptomatic malignant gastroduodenal obstruction successfully treated with duodenal stent placement, acute pancreatitis occurred in 10 (4.1%) of the patients 1-7 days after stent placement. The variables were analyzed. Univariate and multivariate analysis was performed to evaluate factors predictive of acute pancreatitis. Management of acute pancreatitis also was evaluated.

RESULTS

All patients with acute pancreatitis were presented with abdominal pain and distention with vomiting 1-7 days after stent placement, in which 7 patients developed acute janudice. Four patients were cured by fasting and intravenous nutrition, and the remaining 6 cases were managed with percutaneous cholangiography and drain placement (PTCD). Univariate analysis showed acute pancreatitis was associated with location in the descending duodenum (p = 0.001) and stent bridge the duodenal papilla (p < 0.001). Multivariate analysis exhibited that the presence of stent bridged the duodenal papilla (odds ratio (OR), 18.48; 95% CI, 2.298-148.48; p = 0.006) was independent predictors of acute pancreatitis.

CONCLUSIONS

Acute pancreatitis is an uncommon early complication of placement of duodenal stents in patients with malignant gastroduodenal obstruction. Acute pancreatitis occurred most commonly in descending duodenum, and in patients with stent bridged the duodenal papilla. Stent bridged the duodenal papilla may be the most important predictors for acute pancreatitis. Acute pancreatitis can be managed conservatively or by PTCD when developed to acute jaundice.

Green teeth in a premature infant following hemolytic jaundice

Green staining of the dentition is a phenomenon associated with the deposition of bilirubin in the matrix of hard tissue during formation. This article presents a case of green teeth in a patient born 28 weeks premature with a medical history of hemolytic jaundice and grade IV intraventricular hemorrhage at birth.

Vestibular evoked myogenic potentials in term newborn infants with severe hyperbilirubinemia

BACKGROUND

The aim of this study was to determine the effects of severe hyperbilirubinemia on vestibular evoked myogenic potentials (VEMP).

METHODS

A prospective study was designed. Seventeen term infants who suffered from severe hyperbilirubinemia in the first 5 postnatal days of age were included in the study group. The control group consisted of 17 healthy term infants. Audiological evaluation was performed, including tympanometry and transient evoked otoacoustic emissions, and VEMP tests.

RESULTS

All newborns passed audiological evaluation. Biphasic waveforms of VEMP were obtained in all of the 34 infants who had been tested. Both latencies of p13 and n23 were significantly delayed in the severe hyperbilirubinemia group (P < 0.05).

CONCLUSION

This pilot is the first study to show that severe hyperbilirubinemia causes delay in VEMP latencies. We suggest that severe hyperbilirubinemia might affect the vestibular nuclei or the integrity of the inferior vestibular nerve and vestibulospinal tract. Further studies need to explain the relation between hyperbilirubinemia and the vestibular system.

An audit comparing the discrepancies between a verbal enquiry, a written history, and an electronic medical history questionnaire: a suggested medical history/social history form for clinical practice

In everyday practice, dentists are confronted with an increasing number of patients with complex medical problems. There is divergence of opinion among dentists regarding how to obtain a thorough medical/social history.

PURPOSE

The objective of this audit is to produce a standardised medical history in order to identify the medically compromised patient attending the general dental practitioner. At present in the Dublin Dental School and Hospital, there are three different methods: a verbal enquiry, and a written or an electronic questionnaire. This study was undertaken to identify any differences or discrepancies between each of the three methods in eliciting the medical history, and to determine whether one method was superior to the others. The results are used to recommend the most accurate method for obtaining a thorough health history for practitioners, both in a hospital and a general practice setting.

METHOD

One hundred and fifty charts within the Dublin Dental School and Hospital of all new patients at a randomly chosen clinic were selected and then audited: 50 charts from the oral and maxillofacial surgery assessment clinics (written pro forma questionnaire), 50 from the oral medicine clinic (consultant verbal enquiry), and 50 from A&E (electronic questionnaire) were compared to determine if an adequate medical history was taken, and to detect differences and discrepancies in patients' medical histories. The records pertained to 91 females and 59 males. The age distribution was 5-87 years for females and 3-85 years for males. The mean age was 45 years for females and 42 years for males.

RESULTS

The written patient-administered pro forma questionnaire, combined with verbal verification by the clinician/consultant, proved to be the most useful and consistent method for detecting medical problems in dental patients. The consultant verbal enquiry alone showed more inconsistency than the other two methods. Based on these results, a modified questionnaire for use within all departments in the Dental Hospital has been proposed. This may also be suitable for use by general dental practitioners in their practice setting.

CONCLUSION

It is incumbent on the clinician/dentist to evaluate each patient's general health prior to delivering treatment in order to avoid unnecessary and preventable complications. The use of written patient-administered pro forma questionnaires is beneficial but must be verified by the examining clinician/dentist and assessed at each new visit (6-12 monthly) to be contemporaneous.

Modulation of Mrp1 (ABCc1) and Pgp (ABCb1) by bilirubin at the blood-CSF and blood-brain barriers in the Gunn rat

Accumulation of unconjugated bilirubin (UCB) in the brain causes bilirubin encephalopathy. Pgp (ABCb1) and Mrp1 (ABCc1), highly expressed in the blood-brain barrier (BBB) and blood-cerebrospinal fluid barrier (BCSFB) respectively, may modulate the accumulation of UCB in brain. We examined the effect of prolonged exposure to elevated concentrations of UCB on expression of the two transporters in homozygous, jaundiced (jj) Gunn rats compared to heterozygous, not jaundiced (Jj) littermates at different developmental stages (2, 9, 17 and 60 days after birth). BBB Pgp protein expression was low in both jj and Jj pups at 9 days (about 16-27% of adult values), despite the up-regulation in jj animals (2 and 1.3 fold higher than age matched Jj animals at P9 and P17-P60, respectively); Mrp1 protein expression was barely detectable. Conversely, at the BCSFB Mrp1 protein expression was rather high (60-70% of the adult values) in both jj and Jj at P2, but was markedly (50%) down-regulated in jj pups starting at P9, particularly in the 4(th) ventricle choroid plexuses: Pgp was almost undetectable. The Mrp1 protein down regulation was accompanied by a modest up-regulation of mRNA, suggesting a translational rather than a transcriptional inhibition. In vitro exposure of choroid plexus epithelial cells obtained from normal rats to UCB, also resulted in a down-regulation of Mrp1 protein. These data suggest that down-regulation of Mrp1 protein at the BSCFB, resulting from a direct effect of UCB on epithelial cells, may impact the Mrp1-mediated neuroprotective functions of the blood-cerebrospinal fluid barrier and actually potentiate UCB neurotoxicity.

Cholestatic hepatitis and thrombocytosis in a secondary syphilis patient

The incidence of acute hepatitis in syphilis patient is rare. First of all, our patient presented with hepatitis comorbid with thrombocytosis. To our knowledge, this is only the second report of syphilitic hepatitis with thrombocytosis. The 42-yr-old male complained of flu-like symptoms and skin eruptions on his palms and soles. Laboratory findings suggested an acute hepatitis and thrombocytosis. Serologic test results were positive for VDRL. He recovered from his symptoms and elevated liver related enzymes with treatment. Because syphilitic hepatitis can present without any typical signs of accompanying syphilis, syphilis should be considered as a possible cause in acute hepatitis patients.