An unusual case of Zieve's syndrome in a 36-year-old male with latent autoimmune diabetes of adult and disseminated intravascular coagulation

Zieve's syndrome, associated with chronic alcoholism, manifests as hemolytic anemia, transient hyperlipidemia, and cholestatic jaundice. Key symptoms comprise nausea, abdominal pain, and jaundice. Diagnosis relies on recognizing the triad in those with an alcohol use history. Supportive management includes blood transfusions and alcohol cessation. The exact pathophysiology remains uncertain, with hypotheses ranging from alcohol-induced liver damage to autoimmune processes. The report emphasizes diagnostic complexities, particularly when concurrent with autoimmune disorders such as latent autoimmune diabetes of adults or complicated by disseminated intravascular coagulation (DIC). A 36-year-old male with latent autoimmune diabetes of adults and an 18-year history of chronic alcoholism presented with yellowish skin discoloration, abdominal pain, and distension. Physical examination revealed signs of anemia, jaundice, pedal edema, hepatomegaly, splenomegaly, and abdominal tenderness. Over eight admissions, multiple tests revealed severe anemia, thrombocytopenia, elevated bilirubin, and positive autoantibodies. Treatment for suspected autoimmune hepatitis showed no improvement. Subsequent examinations indicated DIC, altered liver function, and cirrhosis progression. A confirmed diagnosis of Zieve's syndrome was made. Upper gastrointestinal endoscopy was done to check for esophageal varices which were banded. The patient was subsequently managed on supportive treatment with multiple blood transfusions and abstinence from alcohol. Prompt recognition of Zieve's syndrome is crucial to avoid unnecessary interventions. Alcohol cessation is the keystone of treatment, emphasizing the need to raise awareness among practitioners. This case points toward the importance of comprehensive evaluation, serial investigations, and multidisciplinary collaboration for accurate diagnosis and management. Further research is needed to enhance understanding and optimize therapeutic strategies.

Multidisciplinary approach for acute MI complicated by ventricular tachycardia, stent thrombosis, and multi-organ failure: A case report

Key Clinical Message

The case highlights the imperative requirement for multidisciplinary action in handling a myocardial infarction case, complicated by rare and severe events like ventricular tachycardia, stent thrombosis, hypoxic brain injury, and multi-organ failure.

Abstract

This article presents a case of a 53-year-old male, who presented with myocardial infarction that was managed by percutaneous coronary intervention and stent placement. However, it progressed to multiple complications in sequence (ventricular tachycardia, stent thrombosis, hypoxic brain injury, and multi-organ failure). Hopefully, the condition of the patient improved after 2 months from GSC-4 to GCS-9 by a multidisciplinary approach and was discharged for home-based treatment.

Factors associated with mortality among moderate and severe patients with COVID-19 in India: a secondary analysis of a randomised controlled trial

OBJECTIVE

Large data on the clinical characteristics and outcome of COVID-19 in the Indian population are scarce. We analysed the factors associated with mortality in a cohort of moderately and severely ill patients with COVID-19 enrolled in a randomised trial on convalescent plasma.

DESIGN

Secondary analysis of data from a Phase II, Open Label, Randomized Controlled Trial to Assess the Safety and Efficacy of Convalescent Plasma to Limit COVID-19 Associated Complications in Moderate Disease.

SETTING

39 public and private hospitals across India during the study period from 22 April to 14 July 2020.

PARTICIPANTS

Of the 464 patients recruited, two were lost to follow-up, nine withdrew consent and two patients did not receive the intervention after randomisation. The cohort of 451 participants with known outcome at 28 days was analysed.

PRIMARY OUTCOME MEASURE

Factors associated with all-cause mortality at 28 days after enrolment.

RESULTS

The mean (SD) age was 51±12.4 years; 76.7% were males. Admission Sequential Organ Failure Assessment score was 2.4±1.1. Non-invasive ventilation, invasive ventilation and vasopressor therapy were required in 98.9%, 8.4% and 4.0%, respectively. The 28-day mortality was 14.4%. Median time from symptom onset to hospital admission was similar in survivors (4 days; IQR 3-7) and non-survivors (4 days; IQR 3-6). Patients with two or more comorbidities had 2.25 (95% CI 1.18 to 4.29, p=0.014) times risk of death. When compared with survivors, admission interleukin-6 levels were higher (p<0.001) in non-survivors and increased further on day 3. On multivariable Fine and Gray model, severity of illness (subdistribution HR 1.22, 95% CI 1.11 to 1.35, p<0.001), PaO₂/FiO₂ ratio <100 (3.47, 1.64-7.37, p=0.001), neutrophil lymphocyte ratio >10 (9.97, 3.65-27.13, p<0.001), D-dimer >1.0 mg/L (2.50, 1.14-5.48, p=0.022), ferritin ≥500 ng/mL (2.67, 1.44-4.96, p=0.002) and lactate dehydrogenase ≥450 IU/L (2.96, 1.60-5.45, p=0.001) were significantly associated with death.

CONCLUSION

In this cohort of moderately and severely ill patients with COVID-19, severity of illness, underlying comorbidities and elevated levels of inflammatory markers were significantly associated with death.

TRIAL REGISTRATION NUMBER

CTRI/2020/04/024775.