Cytomegaloviral colitis in primary CMV viraemia in a young immunocompetent adult

A man in his 20s presented with a 2-week history of fever, fatigue and diarrhoea. On arrival to the emergency department, he had clinical findings of sepsis. The care team initially suspected sepsis secondary to bacterial colitis and administered antibiotics. Further workup including a stool PCR assay for gastrointestinal pathogens failed to establish a diagnosis, and he had no evidence of immune compromise. Colonoscopy revealed mucosal ulceration presumed to be ulcerative colitis. Histopathology obtained after discharge revealed severe colitis with cytomegalovirus (CMV) inclusions. Serological studies indicated a primary CMV infection. To our knowledge, this is the first report of a primary CMV infection presenting as severe colitis and systemic disease in a young immunocompetent patient without underlying disease.

Cardiac tamponade due to perforation of a Roseomonas mucosa pyogenic hepatic abscess as initial presentation of hepatoid carcinoma

Hepatic abscesses can rarely cause pericardial disease by erosion into the pericardial space and present with haemodynamic instability due cardiac tamponade. While rare, these dramatic presentations are more often due to amoebic abscesses than bacterial abscesses. Importantly, a cause must be found for any cryptogenic hepatic abscess regardless of presentation, as there is a high association with underlying malignancy. We report a previously healthy man in his 30s who presented with cardiac tamponade from perforation of a Roseomonas mucosa pyogenic hepatic abscess into the pericardium in the absence of bacteremia and biliary disease. One year later, he was found to have diffusely metastatic hepatoid carcinoma.

Coinfection of enteric fever and hepatitis A

Poor sanitation and contaminated food and water are major risk factors for several infectious diseases like enteric fever and hepatitis A, but their coinfection is uncommon. Although the liver is frequently affected in typhoid fever, substantial hepatic dysfunction in an appropriately treated patient is uncommon. Our patient had high-grade fever with mild transaminitis and blood culture that grew Salmonella typhi Despite being treated with culture-sensitive antibiotic at adequate dosage, he developed jaundice and had worsening transaminitis (>1000 IU/L) which was suggestive of hepatotropic virus infection. Hepatitis A IgM was positive. He was treated appropriately with which clinical and laboratory parameters resolved.

Atypical presentation at acute gastritis: significant gastric wall thickening as a presentation of a primary Helicobacter pylori infection in children

Helicobacter pylori infection could cause chronic inflammation in the stomach and induce peptic ulcer disease or even malignant tumour. The initial infection of the organism happens in childhood but most of cases are latent. We had a case of 10-year-old girl who presented with acute epigastric pain and significant thickening of the stomach wall on CT. The finding seemed atypical for acute gastritis so oesophagogastroduodenoscopy and serology examination were added and the primary infection of H. pylori was confirmed with the exclusion of other possible diagnoses like eosinophilic gastritis and IgA vasculitis. Acute gastritis is one of the most common sickness in children, however, it would be worthwhile considering further investigation including H. pylori infection in a case of atypical presentation to prevent negative consequences derived from chronic H. pylori infection.

Infiltrative gallbladder tuberculosis versus locally infiltrating tumour of the gallbladder: a diagnostic dilemma unmasked by histopathology

Gallbladder tuberculosis (TB) as an isolated infection and is an extremely rare entity even in parts of the world with endemicity. Though it has myriad ways of presentation, it can be cured successfully. We present a case of a 53-year-old man who presented with epigastric fullness and bloating with on and off low-grade fever for 2 months and significant weight loss. He underwent a CT scan, which showed a soft tissue gallbladder mass causing mural thickening of the antrum and lesser curvature. This was followed by a CT-guided core biopsy and gastric antrum biopsy via gastroscopy. Histopathology revealed chronic granulomatous inflammation in both samples. Various clinical presentations of gallbladder TB have been reported in literature, but to the best of our knowledge, the present case has a unique presentation and has never been reported before.

Robotic resection for hydatid disease of the liver

Robotic-assisted surgery for the management of hepatic echinococcosis was introduced in 2016. The advantage it offers over laparoscopy is less rigidity with the use of the 360° rotation of the Endo-Wrist technology, thus allowing the preservation of the integrity of the liver tissue. Herein, we report the first successful robotic resection of the left lobe of the liver for hydatid disease in the Middle East. Our patient is a 71-year-old man found to have a large left hepatic lobe hydatid disease on CT scan. The hydatid liver disease was resected completely with an operation time of 130 min and minimal intraoperative blood loss. Patient did well postoperatively and was discharged home on day 2. Our experience shows that robotic surgery for hydatid disease of the liver can be safely performed, with an excellent outcome to the patient. It also provides unique technical advantages in the field of minimal-invasive surgery.

Acute icteric hepatitis as the first isolated symptom of COVID-19

Patients with COVID-19 may be asymptomatic or present with extrarespiratory symptoms, such as liver injury. It has been reported that 22.5%–46.2% of patients have moderate elevation of liver enzymes. To our knowledge, acute hepatitis has never been described as an isolated symptom of COVID-19 in a previously healthy patient. We report the case of a 53-year-old patient with COVID-19 whose first clinical presentation was acute icteric hepatitis, several days before the development of others symptoms. During the pandemic, we suggest that patients with acute hepatitis be considered as COVID-19 suspects, tested and isolated.

Brevundimonas diminuta coinfection as source of pyogenic liver abscess

Brevundimonas diminuta, a non-fermenting gram-negative bacterium, is emerging as an important multidrug resistant opportunistic pathogen. It has been described in cases of bacteremia, pleuritis, keratitis and peritoneal dialysis-associated peritonitis. We describe, for the first time, a case of pyogenic liver abscess caused by coinfection of B. diminuta and Streptococcus anginosus, and briefly review pyogenic liver abscesses and the literature regarding B. diminuta.

Chronic giardiasis: a rare cause of exocrine pancreatic insufficiency

Exocrine pancreatic insufficiency (EPI) is a major cause of maldigestion/malabsorption syndromes. It is routinely diagnosed in clinical practice with the use of faecal elastase 1 levels, and pancreatic enzyme replacement therapy continues to be the mainstay of treatment. Numerous primary pancreatic and extrapancreatic causes for EPI have been established. Chronic giardiasis is a common condition with symptoms similar to EPI; however, it has also been described as an infrequent cause of EPI. Much remains to be understood about the pathobiology of this association. Here, we present our experience of an intriguing case of severe pancreatic insufficiency in the setting of chronic giardiasis. The patient showed improvement in symptoms over weeks after completion of treatment for chronic giardiasis.

Diaphragmatic paralysis resulting in respiratory failure as a feature of hepatitis E virus-associated neuralgic amyotrophy

Hepatitis E virus (HEV)-associated neuralgic amyotrophy (NA) is often bilateral and severe, involving structures outside the brachial plexus, such as the phrenic nerves or the lumbosacral plexus. We report a case of an HEV-positive man who had presented with brachial neuritis, with significant phrenic nerve involvement, resulting in diaphragmatic paralysis requiring non-invasive ventilation. Prognosis of HEV-associated NA is often unfavourable and recovery is usually incomplete. Identifying HEV-associated NA early could potentially aid in prognostication and management planning, as clinicians and patients would be expectant of its potential features and severity. Respiratory function should be monitored in patients with HEV who suffer from NA, as diaphragmatic paralysis could potentially lead to severe respiration difficulties requiring ventilatory support.

Accidentally discovered high INR in pregnancy unmasks an inherited factor VII (FVII) deficiency that is paradoxically associated with thrombotic tendency

A 32-year-old multiparous obese woman was referred to our center at 37 weeks of twin gestation. She was referred for birth planning following an accidentally discovered high international normalised ratio (INR) in routine preoperative labs. Her history was significant for recurrent pregnancy-associated deep venous thrombosis as well as two early pregnancy losses. Further work-up revealed transaminitis, mild splenomegaly and high lupus anticoagulant titre. A multidisciplinary team of physicians from the high-risk pregnancy, anaesthesiology, haematology, gastroenterology and hepatology departments put a management plan; it culminated into uncomplicated delivery of the patient by repeated caesarian section. The team was also able to figure out the cause of the patient's high INR that is associated with thrombophilia rather than haemophilia.

Anaphylaxis to simultaneous administration of inactivated tissue culture hepatitis A vaccine and purified chick embryo cell rabies vaccine after multiple doses

Both the inactivated hepatitis A vaccine (Aimmugen) and purified chick embryo cell rabies vaccine (PCECV, Rabipur) are well tolerated. Anaphylaxis has rarely been reported as an adverse reaction of these vaccines. There have been no reports or published case reports of anaphylaxis due to Aimmugen. According to the Japanese Ministry of Health, Labour and Welfare Aimmugen adverse reaction report, no cases of anaphylaxis have been reported from April 2013 to August 2016. Twenty cases of anaphylaxis due to PCECV (RabAvert) have been reported from 1997 to 2005 in USA, whereas 2 cases have been reported from 2006 to 2016. We report a case of anaphylaxis after multiple vaccinations in a 24-year-old man with ulcerative colitis, previous medical history of tonsillectomy for IgA nephropathy and no history of allergies.

Small bowel intussusception and Enterobius vermicularis infestation in a 20-year-old woman

A 20-year-old woman presented with abdominal pain and MRI findings of intussusception of the distal small bowel with no identifiable lead point and no visualisation of the appendix. A diagnostic laparoscopy succeeded in manually reducing the intussusception but was unable to find any candidate lead point. Intraoperatively, hyperperistalsis was observed throughout the small bowel which seemed prone to transient intussusception. Incidental appendectomy revealed an uninflamed appendix with Enterobius vermicularis (pinworm) infestation, the most common parasite present in appendectomy specimens worldwide. Although intussusception in young adults is an uncommon occurrence, the unique nature of this case is amplified by the concurrent finding of E. vermicularis infection of the appendix in an adolescent in western Canada, a phenomenon normally observed in paediatric populations with higher incidence in tropical areas. Although the mechanism of intussusception in this patient remains unclear, it is hypothesised that E. vermicularis colonisation acted as an irritant stimulating intestinal hypercontractility with resulting intussusception. Successful medical eradication of the pinworm in this individual may prevent future recurrence.

Fulminant Bacillus cereus food poisoning with fatal multi-organ failure

This case represents a rare fulminant course of fried-rice associated food poisoning in an immunocompetent person due to pre-formed exotoxin produced by Bacillus cereus, with severe manifestations of sepsis, including multi-organ (hepatic, renal, cardiac, respiratory and neurological) failure, shock, metabolic acidosis, rhabdomyolysis and coagulopathy. Despite maximal supportive measures (continuous renal replacement therapy, plasmapheresis, N-acetylcysteine infusion and blood products, and broad-spectrum antimicrobials) and input from a multidisciplinary team (consisting of infectious diseases, intensive care, gastroenterology, surgery, toxicology, immunology and haematology), mortality resulted. This case is the first to use whole genome sequencing techniques to confirm the toxigenic potential of B. cereus It has important implications for food preparation and storage, particularly given its occurrence in home isolation during the COVID-19 pandemic.

Severe acute hepatitis E infection presenting with acute abdomen and meningoencephalitis

We present a case of a 50-year-old man admitted due to acute abdomen, icterus and fever. The patient had a history of sufficiently treated type 2 diabetes and a high daily alcohol consumption, no recent travel history and had a strictly heterosexual and monogamous way of living. A full blood count displayed severe elevated liver enzymes. A CT of the abdomen was performed and revealed steatosis but no acute abdominal pathology. During admission, the patient developed signs of meningoencephalitis. A lumbar puncture was performed, and the cerebrospinal fluid revealed lymphocytic pleocytosis consistent with mild inflammation. Furthermore, hepatitis E was found in the blood and the definitive diagnosis was established. The patient gradually recovered and was discharged within 8 days of admission. To the best of our knowledge, we present the second case describing concomitant hepatitis and meningoencephalitis, resolving spontaneously and not giving rise to sequelae.

Acute CMV hepatitis in an immunocompetent patient

A previously well and immunocompetent 64-year-old woman presented with fever of unknown origin and acute hepatitis. Besides headache and nausea, she had no other symptoms. Her clinical examination was unremarkable with no clear focus of infection. She was thoroughly investigated and her biochemical profile suggested a viral or autoimmune aetiology. Multiple imaging modalities gave no further insight. Her serology and subsequent nucleic acid amplification indicated reactivation of latent cytomegalovirus (CMV). Her symptoms resolved with supportive care and no anti-viral therapy was needed. This case report highlights CMV reactivation leading to acute hepatitis in a well, immunocompetent patient.

Shewanella: an important, emerging and lethal pathogen in a patient with recurrent presentations of cholangitis

We present a case of recurrent cholangitis caused by Shewanella algae, a lethal, emerging pathogen that clinicians should be made aware of. An 86-year-old man with a history of gastrectomy for peptic ulcer disease and a cerebrovascular accident with known choledocholithiasis presented with recurrent episodes of cholangitis that failed conservative antibiotic treatment regimens. Shewanella has been described to have increasing resistance to piperacillin and tazobactam. Both S. algae and multidrug-resistant Escherichia coli were co-isolated in this patient, which required broader spectrum antibiotics for successful treatment and management. A high index of suspicion is required if the history is suggestive of marine or aquatic exposure, which could expose the patient to this lethal pathogen. Re-thinking and re-taking the history are important cornerstones in refining the diagnosis when faced with recurrent presentations of the same problem.

Successful treatment of resistant HCV in a patient with Child-Pugh B cirrhosis using sofosbuvir and glecaprevir/pibrentasvir

Treatments for hepatitis C are now well tolerated with very high rates of sustained virological response and almost all patients have a suitable and effective treatment option. However, treatment options remain limited for a minority of patients and are limited for patients with Child-Pugh B or C cirrhosis due to the risk of decompensation with protease inhibitors. We present a case of successful treatment with glecaprevir/pibrentasvir (Maviret) and sofosbuvir in a patient with Child-Pugh B cirrhosis and resistant virus who had failed three previous attempts of treatment including two courses of direct acting antiviral agents and in whom liver transplantation was deemed unsuitable. We propose that the balance of risks favours a trial of treatment with protease inhibitors in some circumstances in patients with Child-Pugh B cirrhosis where no other suitable alternatives including treatment post liver transplantation are available/appropriate.

Gallbladder wall thickening on bedside ultrasound in a child with Epstein-Barr virus infection

Gallbladder wall thickening (GBWT) is rarely reported in children with acute Epstein-Barr virus (EBV) infection. We present a child with EBV infection who was found on point-of-care ultrasound to have GBWT without signs of cholecystitis that subsequently resolved without intervention. We expect the proliferation of mobile and handheld sonography to increase the number of bedside examinations in febrile children. This, in turn, will increase the incidence of GBWT found in patients with EBV infection and without right upper quadrant pain. Prospective study is needed to define the incidence of GBWT in children with EBV infection.

Fatal Clostridium septicum febrile neutropenia during adjuvant chemotherapy for early breast cancer

We report the case of a 76-year-old female patient with early breast cancer (hormone receptor-positive erbb2 amplified) that had started adjuvant chemotherapy with docetaxel, carboplatin and trastuzumab (TCH). Eight days after the first cycle of TCH chemotherapy, the patient was diagnosed with grade 1 oral mucositis, treated conservatively. The next day she started with nausea, vomiting, chills and fever, followed by a generalised tonicoclonic seizure. She presented to the emergency department with fever, hypotension and mild abdominal tenderness. Grade 4 neutropenia (370 μL/mL) and severe metabolic acidosis were documented. An abdominal CT scan documented extensive ischaemic bowel changes, with gas in portal and mesenteric veins, and pneumoretroperitoneum. Despite broad spectrum antibiotics and fluid resuscitation, she died 4 hours after admitted to hospital. Blood cultures collected on hospital admission eventually grew Clostridium septicum bacteria, an extremely rare infection in patient with breast cancer.

CMV coinfection in treatment refractory immune checkpoint inhibitor colitis

As immune checkpoint inhibitors (ICIs) are increasingly used, clinicians are more frequently encountering the side effects of these therapies. ICIs have been implicated in numerous adverse effects against healthy tissues. We present a case of a patient who developed treatment refractory checkpoint inhibitor colitis. Following colonoscopy, it was discovered that this patient had cytomegalovirus (CMV) coinfection. This case report highlights the importance of undertaking an appropriate assessment, including endoscopic and histologic investigation, of patients with presumed ICI colitis. Accurately diagnosing a superimposed CMV colitis changes clinical management and can improve patient outcomes.

Walled-off pancreatic necrosis: a staged multidisciplinary step-up approach

Walled-off pancreatic necrosis (WOPN) is a rare complication of pancreatitis. We present the case of a woman in her eighties admitted for diffuse abdominal pain. She had a palpable abdominal mass and the CT scan showed necrosis throughout the tail of the pancreas, a peripancreatic and retrogastric hydroaerial collection (19 cm of diameter) and a calculus in the main biliary duct, thus establishing a diagnosis of emphysematous necrotising obstructive pancreatitis. A step-up approach was decided, first with removal of the biliary calculus, followed by a waiting period of 4 weeks in which the patient was under intravenous antibiotics. At re-evaluation, the CT scan showed a smaller and more organised collection, bounded by a wall, defining WOPN. At this stage, transgastric drainage via echoendoscopy was attempted, without success, followed by percutaneous CT-guided drainage, also with little effect. Surgical necrosectomy was then executed, as a final step, with a successful outcome.

Campylobacter colitis leads to toxic megacolon and multiple organ failure

A 58-year-old woman presented to the emergency department in a district general hospital with severe abdominal pain and diarrhoea, after collapsing at home. She was admitted to the intensive care unit (ICU) in septic shock, and with acute kidney injury. An initial CT scan was suggestive of colitis. She was treated for suspected gastroenteritis and her microbiology results showed Campylobacter coli as the causative organism. She failed to respond to antibiotics, and underwent serial contrast CTs which showed no progression of colitis. Colonoscopy performed on day 10 of her admission, however, revealed fulminant colitis. After a multidisciplinary meeting among gastroenterologists, general surgeons and intensivists, the patient underwent total colectomy with ileostomy. She made a slow but steady recovery in ICU, and subsequently in the ward, and was discharged to a local community hospital for further rehabilitation.

Treatment failure after multiple courses of triclabendazole in a Portuguese patient with fascioliasis

Fascioliasis is a trematode flatworm infection caused by Fasciola hepatica Humans are incidental hosts, and the infection is most often acquired by eating watercress grown in contaminated water in livestock-rearing areas. Triclabendazole is the only highly effective treatment, with a reported cure rate of >90%. Treatment failure may be due to several factors, though resistance is rare in humans and scarcely reported, most probably a reflection of the widespread use of anthelmintics in livestock. There are three papers describing cases of treatment failure, possibly due to resistance, in the Netherlands, Chile and Peru. We document for the first time one case of failure after multiple treatment courses with triclabendazole in Portugal, probably due to resistance to the anthelmintic. Our aim is to alert for the emergence of resistance across continents, with consequent predictable difficulties in the management of the disease and encourage more investigation in the field.

Multiple liver abscesses caused by S treptococcus intermedius bacteremia in the setting of a routine dental cleaning

Streptococcus intermedius is a Gram-positive cocci, normally found in the oral cavity and gastrointestinal tract. It has been associated with deep-seated purulent abscesses commonly in the brain or liver in immunocompromised patients. Here, we discuss the case of a 21-year-old immunocompetent patient that presented with septic shock in the setting of multiple pyogenic liver abscesses with positive blood cultures for S. intermedius The patient had a dental cleaning 3 months prior to admission. The abscesses resolved with ultrasound guided drainage and antibiotic therapy.

Acute Epstein-Barr infection presenting as cholecystitis with ascites

A young female patient presented with features of ascites and cholecystitis. She was subsequently diagnosed with an acute Epstein-Barr virus infection. This is a rare presentation of a common infection. The patient was managed conservatively and the illness resolved within 6 weeks.

Streptococcus constellatus: a rare causative agent of pyogenic liver abscess

A 26-year-old man who was previously well presented to the emergency in septic shock. He had a preceding history of fever, right upper abdominal pain and jaundice. On examination, there was tenderness over the right hypochondrium and epigastrium, without features of generalised peritonitis. His blood tests were suggestive of sepsis with deranged liver function tests. CT scan of the abdomen showed multiples abscesses in various segments of the liver and a thrombus in the inferior venacava, without any other intraabdominal focus of infection. The abscess was aspirated under sonographic guidance, and the cultures grew Streptococcus constellatus species of S. milleri group (SMG). He received crystalline penicillin, based on culture sensitivity and underwent drainage of the abscess. There was a clinical improvement and he was subsequently discharged in a stable condition. On 3 months follow-up, there was a complete resolution of the liver abscess and normalisation of the liver function tests.

Atypical presentation of Clostridioides difficile pseudomembranous colitis with laboratory rejection of stool specimen

Clostridioides (formerly Clostridium) difficile is a major cause of nocosomial infection in the USA and worldwide. It has a wide spectrum of presentation, ranging from an asymptomatic carrier state to fulminant colitis. Pseudomembranous colitis is a manifestation of severe C. difficile infection (CDI), typically with progressive symptoms including watery diarrhoea, abdominal cramping and fevers and elevated white cell count and/or creatinine. It is diagnosed on three levels, including clinical assessment, stool assays and visualisation of the colonic mucosa. Laboratories will reject stools that do not meet criteria for testing. In the era of molecular testing for the presence of toxigenic C. difficile DNA, which only indicates the potential for infection, it is vital to use clinical evaluation in the diagnosis of CDI. We present an atypical case of pseudomembranous colitis affecting the right colon in a patient whose stools were rejected multiple times for C. difficile testing.

Fungal appendicitis in a non-immunocompromised woman

We describe a previously fit and well 54-year-old woman who presented with 3 weeks of right-sided lower abdominal pain with CT showing a non-specific thickening of the caecal/appendiceal wall. Although initially concerning for a neoplastic process, histology demonstrated yeast-like organisms colonising and invading into the appendiceal wall, confirming the diagnosis of fungal appendicitis. Fungal appendicitis is an important clinical entity that has previously been reported to affect immunocompromised individuals. Although uncommon among the non-immunocompromised individuals, it should not be neglected as a possible diagnosis in patients presented with non-specific abdominal pain.

Rare and unusual case of hepatic and disseminated tuberculosis in an immunocompetent patient

Mycobacterium tuberculosis complex disease (tuberculosis (TB)) of the liver is rare and liver abscesses as a result are even rarer. In an immunocompetent individual, the disease tends to be localised. To the best of our knowledge, we report one of the most severe TB involvements of the liver in an immunocompetent individual. A young woman with a history of previous TB infection, presented in septic shock. Scans showed a liver filled with possible abscesses, one of which was aspirated and confirmed TB. Multiple HIV tests were negative but she remained lymphopaenic. Although she improved substantially with anti-tuberculous treatment, she later developed non-tuberculous central nervous system disease that we were unable to fully explain. Despite a stormy recovery period, she continues to do well.

Abdominal tuberculosis with a Pseudo-Sister Mary Joseph nodule mimicking peritoneal carcinomatosis

A 46-year-old woman presented in severe abdominal pain on a background of 3 months of weight loss and intermittent vomiting. She had visited East Africa 6 months prior but reported no unwell contacts. On examination, she had generalised abdominal tenderness, distension and a painful paraumbilical swelling. CT scanning confirmed small bowel obstruction and revealed widespread peritoneal nodules, lymphadenopathy, ascites and a soft tissue paraumbilical mass. CA-125 tumour marker was elevated. However, transvaginal ultrasound scanning showed normal-appearing ovaries. She underwent a diagnostic laparoscopy for ascitic fluid analysis and biopsy of omental and peritoneal nodules, which revealed a lymphocytic exudate and caseating granulomas, respectively. Interferon-γ release assay and repeated stains for acid-fast bacilli were negative. She was commenced on antituberculous chemotherapy for a presumed diagnosis of abdominal tuberculosis. Positive culture results 2 weeks later confirmed Mycobacterium tuberculosis infection. The patient experienced a complete resolution of symptoms within 6 weeks of treatment.

Autoimmune liver disease following acute hepatitis A infection

A male patient in his late 30s presented to our outpatient clinic at Mortimer Market Centre with worsening liver transaminases tests 2 months after a resolved acute hepatitis A infection. A diagnosis of parainfectious autoimmune-like hepatitis phenomena was made based on the history, laboratory and histological features.

Glecaprevir/pibrentasvir-associated acute liver injury in non-cirrhotic, chronic HCV infection without HBV co-infection

The combination of glecaprevir and pibrentasvir was recently approved for chronic hepatitis C virus (HCV) infection with recommended treatment duration of 8-12 weeks depending on previous treatments, viral genotype and cirrhosis status. Although liver injury was reported with other protease inhibitors in the presence of cirrhosis or hepatitis B virus (HBV) co-infection, glecaprevir/pibrentasvir treatment is not known to cause liver injury. We report a patient with chronic HCV infection who despite the absence of cirrhosis and HBV co-infection developed acute liver injury that completely resolved after glecaprevir/pibrentasvir withdrawal. Interestingly, sustained HCV virologic response was achieved after only 3 weeks of glecaprevir/pibrentasvir treatment.

Abdominal tuberculosis in a spigelian hernia

Abdominal tuberculosis is a common form of extrapulmonary tuberculosis. Often it is difficult to diagnose due to vague symptoms and lack of clinical findings. Spigelian hernia is a rare type of hernia located in the semilunar fascia of the abdominal rectus muscular sheath. We report on a 19-year-old Greenlandic Inuit man with a spigelian hernia as the primary presentation of abdominal tuberculosis. Abdominal tuberculosis presenting with a spigelian hernia is extremely rare, and the case illustrates that tuberculosis may present in myriad ways. The incidence of tuberculosis in Greenland is among one of the highest in the world, and we also review the history and incidence of tuberculosis in this Arctic country.

False-positive serologies for acute hepatitis A and autoimmune hepatitis in a patient with acute Epstein-Barr virus infection

Acute hepatitis remains a diagnostic challenge, and numerous infectious, metabolic and autoimmune diseases need to be effectively excluded. We present a case of a young woman with malaise, fever, jaundice and deranged liver function tests. Testing for Epstein-Barr virus (EBV) virus capsid antigen IgM/IgG was positive. Total IgG was elevated, along with positive serology for anti-hepatitis A virus (HAV)-IgM, antinuclear antibodies (ANAs) and soluble liver antigen (SLA) leading to the differential diagnosis of acute hepatitis A and autoimmune hepatitis. No specific treatment was started and liver function gradually improved. At week 4, HAV IgG and IgM were negative. At month 4, ANA and SLA were negative and total IgG normalised; EBV nuclear antigen became positive. Testing for EBV is an investigation required at baseline in acute hepatitis and physicians should carefully evaluate serological results, including those for viral and autoimmune hepatitis that may be falsely positive in infectious mononucleosis.

Acalculous acute cholecystitis during the course of an enteroviral infection

Gallbladder diseases are uncommon in children. Acalculous acute cholecystitis, although rare, is the most frequent form of acute cholecystitis in childhood. In acalculous acute cholecystitis, clinical presentation and laboratory findings are unspecific, making the diagnosis challenging. Abdominal ultrasonography is the first-line exam. Most cases of paediatric acalculous acute cholecystitis have been described in critically ill patients, but can occur in previously healthy children, without underlying diseases or severe conditions. The authors present a clinical report of a child with acalculous acute cholecystitis and enteroviral infection. Diagnosis, treatment, clinical course and prognosis are described. Pathophysiology, aetiology, diagnosis and treatment of acalculous acute cholecystitis are also discussed.

Salmonella enterica serovar enteritidis peritonitis with spontaneous intestinal perforation in an immunocompetent patient

Few data reported non-typhoidal Salmonella peritonitis in immunocompromised patients. We reported the case of a man without immunosuppression or predisposing factor, who developed Salmonella enterica serovar Enteritidis peritonitis with spontaneous intestinal perforation. After emergent surgery, the patient was transferred to intensive care unit (ICU) because of respiratory, renal and haemodynamic failures. When S. enterica serovar Enteritidis was identified, antibiotics were de-escalated for ceftriaxone and metronidazole for 5 days. No immunosuppression was found. Evolution was favourable, and the patient has been discharged from the ICU on day 8. The originality of this case arises from a perforation peritonitis secondary to S. enterica without any immunosuppression. In absence of non-Typhi Salmonella data, we treated this patient as a typhoid perforation: surgical treatment, antibiotic association and supportive care.

Isolated hepatobiliary tuberculosis: a diagnostic challenge

Hepatobiliary system involvement is frequently seen as part of disseminated tubercular infection. But primary isolated hepatobiliary tuberculosis with no evidence of tuberculosis elsewhere in the body is extremely rare. Isolated hepatobiliary tuberculosis can cause diagnostic dilemma as the clinical, laboratory and imaging features are non-specific in majority of the cases. We report the case of a 50-year-old woman who presented with hepatobiliary tuberculosis with no pulmonary or extra hepatic involvement. Liver function tests were abnormal and ultrasonography (USG), CT and MR cholangiopancreatography showed multiple focal lesions in the liver. The diagnosis of tuberculosis was confirmed by a USG-guided biopsy of the liver lesions. In endemic regions with the presence of supportive imaging findings, in the appropriate clinical setting, the possibility of hepatic tuberculosis should be considered and diagnosis has to be confirmed with histopathological examination.

Streptococcus pyogenes primary peritonitis

Streptococcus pyogenes, a Gram-positive bacterium, is a rare cause of primary peritonitis. Diagnosed on imaging and with positive growth in blood cultures, a case of primary peritonitis caused by S. pyogenes is discussed here, with a brief literature review, and used to discuss several key principles of antibiotic use, including selection of antibiotic, investigations and non-pharmacological management of infection.

Treating chronic hepatitis E: when is enough enough?

We present a 38-year-old white British man who was taking long-term immunosuppressive medication following kidney transplantation. On routine review, he was noted to have an isolated and asymptomatic rise in alanine aminotransferase. After thorough investigation, he was found to have positive IgM and IgG serology to hepatitis E virus-and given the duration of his transaminitis, he was determined to have chronic hepatitis E infection. Treatment options were complicated by the presence of his kidney transplant, by chronic anaemia and by his wish for concomitant fertility treatment. Ribavirin therapy was instituted with a dramatic and immediate drop in serum viral load, although stool viraemia persisted. No clear protocols guide duration of treatment in chronic hepatitis E infection, but protracted faecal virus shedding predicts viral recrudescence, and treatment should continue at least until the stool is clear of virus.

Honeycomb and necklace signs in liver abscesses secondary to melioidosis

Melioidosis is endemic in Southeast Asia and tropical Australia with varying clinical features from benign skin lesions to fatal septicaemia. Imaging plays an important role in evaluation of the melioid liver abscesses. A 45-year-old man with underlying diabetes presented with fever and lethargy for 2 weeks and abdominal pain for 2 days. His liver was enlarged on examination. Blood investigations revealed mild leucocytosis and raised liver enzymes. Ultrasound showed multiple multiloculated hypoechoic lesions throughout the liver and spleen. CT of abdomen confirmed that some liver lesions were made up of asymmetric locules of varying sizes (honeycomb sign), while others had hypodense centre with small symmetric peripheral locules in radial fashion (necklace sign). Blood culture was positive for Burkholderia pseudomallei He was subsequently treated with ceftazidime for a month followed by oral trimethoprim-sulfamethoxazole for 3 months. Follow-up CT of abdomen a month after diagnosis and treatment showed resolving hepatic and splenic lesions.

Successful twice interrupted therapy of HCV infection in patients with cirrhosis with hepatocellular carcinoma before and after liver transplantation

We are presenting the case study of the patient diagnosed at the age of 37 with liver cirrhosis due to genotype 1b hepatitis C virus infection. At the age of 46, he was diagnosed with hepatocellular carcinoma with subsequent resection of the tumour in May 2015. In December 2015, the treatment was started with ombitasvir, paritaprevir/ritonavir and dasabuvir (3D) with ribavirin (RBV) 1000 mg per day. After 24 days of this treatment, the patient received a deceased donor liver transplantation, followed by 18-day interruption of 3D therapy. Due to the anaemia, RBV dose was reduced to 600 mg per day for the rest of the treatment. At the 11th week of 3D+RBV treatment, there was another 8-day long discontinuation of therapy due to the postoperative wound infection. In total, the patient received 24 weeks of 3D+RBV treatment, achieving sustained virological response at week 24 post-treatment.

Invading beyond bounds: extraintestinal Clostridium difficile infection leading to pancreatic and liver abscesses

Clostridium difficile has become a common healthcare-associated infection over the past few years and gained more attention. C. difficile was estimated to cause almost half a million infections in USA in 2011 and 29 000 died within 30 days of the initial diagnosis. Although colitis due to C. difficile is the most common presentation, there have been reported cases of extraintestinal infections. As per our review of literature, this is the third reported case of liver abscess due to the organism.