Acute Isolated Hyperbilirubinemia as a Presentation of Alcoholic Liver Disease: A Case Report and Literature Review

Associations between per- and polyfluoroalkyl substances, liver function, and daily alcohol consumption in a sample of U.S. adults

BACKGROUND AND AIM

Per- and polyfluoroalkyl substances (PFAS) are ubiquitous in the environment and in the serum of the U.S.

POPULATION

We sought to evaluate the association of PFAS independently and jointly with alcohol intake on liver function biomarkers in a sample of the U.S. general population.

METHODS

Using data from the National Health and Nutrition Examination Survey (2003-2016; N = 11,794), we examined the five most historically prevalent PFAS with >75% detection rates. We estimated odds ratios (OR) and 95% confidence intervals (CI) for the association between PFAS (quartiles and log-transformed continuous, ng/mL) and high levels (>95th percentile) of liver injury biomarkers using logistic regression models adjusted for key confounders. We evaluated interactions between PFAS and alcohol consumption and sex via stratified analyses and conducted sub-analyses adjusting for daily alcohol intake among those with available drinking history (N = 10,316).

RESULT

Serum perfluorooctanoic acid (PFOA) was positively associated with high levels of alanine transferase (ALT) without monotonic trend (ORQ4vsQ1 = 1.45, CI: 0.99-2.12; p-trend = 0.18), and with increased aspartate transaminase when modeled continuously (OR = 1.15, CI: 1.02-1.30; p-trend = 0.03). Perfluorooctane sulfonate (PFOS) and perfluorohexane sulfonate (PFHxS) were both inversely associated with alkaline phosphatase while a trend was evident only for PFHxS (p = 0.02). A non-monotonic inverse association was observed with PFOA (p-trend = 0.10). The highest quartile of PFOS was associated with high total bilirubin (TB; ORQ4vsQ1 = 1.57, CI: 1.01-2.43, p-trend = 0.02). No significant associations were found between any PFAS and γ-glutamyl transpeptidase. We found no associations for perfluorodecanoic acid and perfluorononanoic acid. We observed some suggestive interactions with alcohol intake, particularly among heavy drinkers.

CONCLUSION

Consistent with other studies, serum levels of PFOA, PFHxS and PFNA were positively associated with high levels of ALT, and we also observed weak positive associations between some PFAS and TB. Associations observed among heavy drinkers warrant additional evaluation.

Direct/Conjugated Hyperbilirubinemia as an Uncommon Presentation of Acute Alcoholic Hepatitis: A Case Report

Alcoholic liver disease (ALD) is a common pathology in clinical practice and is clinically diverse. Acute alcoholic hepatitis is an acute inflammation of the liver with or without underlying cholestasis and steatosis. In this case, we are presenting a 36-year-old male with a past medical history of alcohol use disorder who presented with two weeks of right upper quadrant abdominal pain and jaundice. However, direct/conjugated hyperbilirubinemia with relatively low aminotransferases in labs prompted investigation for obstructive and autoimmune hepatic pathologies. Unrevealing investigations prompted consideration of acute alcoholic hepatitis with cholestasis and a course of oral corticosteroids that gradually improved the patient's clinical symptoms and liver function test. This case helps to remind clinicians that although ALD is usually associated with indirect/unconjugated hyperbilirubinemia and elevated aminotransferases, presentation of ALD with mainly direct/conjugated hyperbilirubinemia with relatively low aminotransferases is a possibility. Although imaging tests should be pursued to rule out obstructive etiologies, invasive tests and liver biopsies are not indicated in typical clinical settings.

Ustilaginoidin D induces hepatotoxicity and behaviour aberrations in zebrafish larvae

Ustilaginoidins, a group of bis-naphtho-γ-pyrones, are one of the major mycotoxins produced by Ustilaginoidea virens. This group of bis-naphtho-γ-pyrone mycotoxins has been demonstrated to have antibacterial and immunological inhibitory activities and strong cytotoxicity to human oral epidermoid carcinoma. However, little is yet known about the toxicity of ustilaginoidins to animals or toxicity mechanisms. In this study, toxicity assays to zebrafish larvae show that ustilaginoidin D is highly toxic to zebrafish with an LC₅₀ of ∼7.50 μM. Ustilaginoidin D causes an obvious yolk sac absorption delay and liver damage in zebrafish, which is indicated by liver atrophy and the increased alanine and aspartate transaminase activities. Interestingly, different doses of ustilaginoidin D can alter zebrafish movement behavior in a distinct manner. Transcriptome analyses show that global gene expression profiling in zebrafish is significantly changed in response to ustilaginoidin D exposure. KEGG pathway analyses reveal that differentially expressed genes are enriched in the pathways related to lipid metabolism and hyperbilirubinemia, which are indicators of severe liver injury. Consistently, the expression of the marker genes for hepatotoxic responses is significantly induced by ustilaginoidin D. The findings indicate that ustilaginoidin D induces lipid metabolism disorders and hepatotoxicity in zebrafish larvae and poses a potential risk to food safety.