SARS-CoV-2 has caused a global pandemic of an acute respiratory illness known as COVID-19. Patients with solid organ transplants receiving chronic immunosuppressive therapy are at risk of severe disease caused by opportunistic pathogens, including cytomegalovirus (CMV). We present the case of a renal transplant recipient presenting with hypoxic respiratory failure because of severe COVID-19, whose course was complicated by ganciclovir-resistant CMV pneumonitis.

Approximately 20% of patients with newly diagnosed colorectal cancer present with distant metastatic disease. Brain metastasis from colorectal cancer is uncommon and usually associated with metachronous metastases in other organs. We describe a rare case of a 49-year-old patient presenting with headaches and left-sided weakness found to have a solitary brain metastasis from primary rectal cancer. Primary rectal cancer, young age, lung and liver metastases, and KRAS mutation are risk factors associated with brain metastases in patients with colorectal cancer. Intracranial imaging should be considered as part of the workup in the staging of colorectal cancer in patients who are at high risk of brain metastasis.

Introduction: Honey exhibits a variety of bacteriostatic and bactericidal factors. Due to its variety of antimicrobial and wound healing properties, honey is an effective remedy in wound infections even caused by microorganisms resistant to antibiotics. Nevertheless, there are many known benefits of normal saline soaked gauze dressing as well such as its osmotic properties, cost-effectiveness, and easy availability with no side effects. It is believed that honey as well as normal saline could be used in the management of infected and non-healing wounds and ulcers, pressure wounds, burns, boils, pilonidal sinuses, diabetic and venous ulcers and even malignant wounds with respect to wound size and cleanliness. Purpose of Study: The purpose of this study is to compare the effect of topical honey versus normal saline soaked dressing application in the management of cosmetically improved postoperative infected wounds in pediatric urology patients. Material and Methods: This Randomized Controlled trial was conducted at the Institute of Kidney Diseases (IKD), Hayat Abad Medical Complex (HMC), Peshawar commencing from January 2019 till December 2019 i.e., over a period of one year. Pediatric patients with postoperative wound infections with positive wound cultures were included in the study. The patients were divided into two groups. In group A normal saline soaked dressing was applied and in group B honey was applied three times a day each. Results: A sample size of 60 patients was taken with males 35(58.3%) and females 25(41.7%). Mean age was 5 years with standard deviation of 2.15 with minimum age 1 year and maximum age 10 years. The bacteria on wound culture came out to be Pseudomonas aeruginosa, Staphylococcus aureus and Escherichia coli in descending order. Patients were divided into two groups. Group A included 30 patients with normal saline soaked dressing application to the wound while Group B included 30 patients with honey application to the infected wound. Both groups were compared in terms of scar improvement and results were found statistically significant 0.028 in group B (Honey). Conclusion: Honey can be used safely and effectively for the management of postoperative surgical site infections in pediatric urology patients as compared to normal saline soaked dressings. Keywords: Honey, postoperative infected wound, pediatric patients

INTRODUCTION: Multiple antibiotics have the well documented adverse reactions of Stevens-Johnson syndrome, toxic epidermal necrolysis, and liver injury. Oseltamivir is not known to cause any of the above reactions. We present a patient who suffered both toxic epidermal necrolysis and drug induced liver injury (DILI) secondary to oseltamivir. CASE DESCRIPTION/METHODS: A 40-year-old female with systemic lupus erythematosus (SLE) on hydroxychloroquine and azathioprine for several years presented with community acquired pneumonia and rash concerning for Stevens-Johnson syndrome (SJS). She was also found to have newly elevated liver chemistries in a hepatocellular pattern. Her only new medication was oseltamivir which had been started 48 hours prior to presentation for empiric treatment of influenza. She was transferred to our tertiary care academic medical center burn unit for further management of SJS which eventually progressed to toxic epidermal necrolysis (TEN) (confirmed via dermatopathology). On arrival to our institution, her pattern of abnormal liver chemistries evolved into that of a cholestatic hepatitis with a peak conjugated hyperbilirubinemia of 16.7mg/dL, alkaline phosphatase of 1087 U/L, AST of 400 U/L, and ALT of 708 U/L. Her TEN started to improve with supportive care and cessation of oseltamivir. She underwent MRCP which revealed possible bile duct stricturing without biliary ductal dilatation. Her ANA was positive with a titer of 1:640, anti-smooth muscle antibody was negative, anti-mitochondrial antibody was negative, and IgG level was within normal limits. She underwent liver biopsy which was consistent with drug induced liver injury. Her liver chemistries eventually started to improve and she was discharged from the hospital with continued improvement on follow up. DISCUSSION: Oseltamivir is an antiviral sometimes used for influenza infection. Very few reports exist regarding oseltamivir’s association with SJS/TEN, and even less on its association with liver injury. Our case is unique in that a patient developed both TEN as well as drug induced liver injury secondary to oseltamivir which are rare but important differential diagnoses to be aware of for patients who develop rash or elevated liver enzymes while being treated with oseltamivir.

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Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in diabetics. However, it is not the sole cause of chronic liver disease in diabetics. We present a case of an 18-year-old male with poorly controlled type I diabetes mellitus who presented for evaluation of asymptomatic elevated liver chemistries. An extensive autoimmune, metabolic, and infectious workup was unrevealing. Liver biopsy was consistent with glycogenic hepatopathy without evidence of steatosis or fibrosis. Increased glycemic control led to his liver enzymes trending down. In conclusion, glycogenic hepatopathy should be considered in poorly controlled type 1 diabetics with elevated liver chemistries.

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