We report a case of a bodybuilder who took a regimen of anabolic steroids containing stanozolol and testosterone propionate for 8 weeks which led to the development of jaundice and severe pruritus with serum total bilirubin reaching 41.22 mg/dL. Despite supportive care with fluid and albumin therapy, serum creatinine was progressively increasing. He underwent 6 successful sessions of plasma exchange (PE) with marked improvement at the end of the sessions. Three months after discharge, the patient's creatinine and total bilirubin levels were 1.08 mg/dL and 1.2 mg/dL, respectively.

ObjectiveTo examine associations of behavioural risk factors, namely cigarette smoking, physical activity, dietary intakes and alcohol consumption, with blood lipids profile.Design and participantsData drawn from a cross-sectional study involving participants aged 18 years and over (n=363) from the nationwide WHO STEPwise Nutrition and Non-communicable Disease Risk Factor survey in Lebanon.MeasuresDemographic characteristics, behaviours and medical history were obtained from participants by questionnaire. Dietary assessment was performed using a 61-item Culture-Specific Food Frequency Questionnaire that measured food intake over the past year. Lipid levels were measured by the analysis of fasting blood samples (serum total cholesterol (TC), triglycerides (TG), very low-density lipoprotein (VLDL), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C)).ResultsCurrent cigarette smoking, alcohol consumption and low physical activity were prevalent among 33.3%, 39.7% and 41.6% of the sample, respectively. The contributions of fat and saturated fat to daily energy intake were high, estimated at 36.5% and 11.4%, respectively. Abnormal levels of TC, TG, VLDL, LDL-C and HDL-C were observed for 55.4%, 31.4%, 29.2%, 47.5% and 21.8% of participants, respectively. Adjusting for potential confounders, cigarette smoking was positively associated with higher odds of TG and VLDL (OR=4.27; 95% CI 1.69 to 10.77; and 3.26; 95% CI 1.33 to 8.03, respectively) with a significant dose–response relationship (p value for trend=0.010 and 0.030, respectively). Alcohol drinking and high saturated fat intake (≥10% energy intake) were associated with higher odds of LDL-C (OR=1.68; 95% CI 1.01 to 2.82 and OR= 1.73; 95% CI 1.02 to 2.93). Physical activity did not associate significantly with any blood lipid parameter.ConclusionThe demonstrated positive associations between smoking, alcohol drinking and high saturated fat intake with adverse lipoprotein levels lay further evidence for clinical practitioners, public health professionals and dietitians in the development of preventive strategies among subjects with a high risk of cardiovascular diseases in Lebanon and other neighbouring countries with similar epidemiological profile.

Background: Health-related quality of life (HRQoL) for adults with chronic and acute illnesses informs health and economic policy for pandemic recovery. Our primary aim was to compare HRQoL of 3 illness groups of outpatient adults: those with diabetes, those who survived a hospitalization for COVID-19, and those who had a respiratory virus not COVID-19. The secondary aim was to compare the group domain summary scores to the referent general population.Methods: We identified the 3 groups from the electronic medical record and invited them to complete the SF-36 survey. Analysis of variance and post hoc testing was used for univariate analyses followed by linear regression.Results: One hundred thirty-two adults completed the survey. The groups differed least for physical functioning and most for emotional/mental health. The hospitalized group had the greatest limitation in role due to emotional issues. All groups had significantly lower social functioning scores than the general population. Linear regression showed lower HRQoL domain score in role limitations due to emotional issues adjusted for age, race, and gender for the hospitalized group.Conclusion: SF-36 scores show the decrease in HRQoL that outpatient adults have suffered, mostly in the emotional domain, regardless of illness group during the COVID-19 pandemic.

Objective We aimed to examine arterial stiffness and vitamin K2 status in migraine subjects by comparison to controls. Background Migraine is a primary headache disorder that has been associated with an increased risk of cardiovascular events. Mechanisms underlying this increased risk, however, remain unclear. Vitamin K2 deficiency emerged as a cardiovascular risk factor, but vitamin K2 status has never been explored in migraine subjects. Design and Methods This is a case‐control, single‐center, observational study that includes a cohort of subjects with migraine and their age‐ and sex‐matched controls. Arterial stiffness was measured using carotid‐femoral pulse wave velocity (cfPWV). Dephosphorylated‐uncarboxylated matrix‐Gla‐protein (dp‐ucMGP) was used as a marker for vitamin K2 status. A propensity‐matched scoring method was used. Results A total of 146 patients (73 matched pairs) were included in this study, of whom 89% were women with a mean age of 31.9 ± 8.4 years. Compared with controls, migraine patients had statistically significantly higher mean cfPWV (7.2 ± 1.1 vs 6.4 ± 0.8 m/s, 95% confidence interval (CI) of mean difference [0.45, 1.08], P < .001), as well as higher dp‐ucMGP (454.3 ± 116.7 pmol/L vs 379.8 ± 126.6 pmol/L, 95% CI of mean difference [34.63, 114.31], P < .001). Higher cfPWV was associated with higher dp‐ucMGP concentrations only in the migraine with aura (MWA) group. Moreover, migraine subjects had a higher frequency of vitamin K2 deficiency (dp‐ucMGP ≥ 500 pmol/L) compared to controls, but this association was not statistically significant (23/73 [31.5%] vs 16/73 [21.9%], P = .193). Conclusions Individuals with migraine have worse indices of arterial stiffness as compared with their age‐ and sex‐matched control subjects. This increase in arterial stiffness is associated with an increase in markers of vitamin K2 deficiency in the MWA group.

Cost-effectiveness does not correlate with a drug's excluded or recommended status. Lack of cost-effectiveness evidence favors a drug's excluded status.

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A 10-year-old, previously healthy girl presented with asthenia and fever of 3 days' duration. Initial investigations revealed mild leukopenia and severe hemolytic anemia (hemoglobin 5 4.9 mg/dL) with a markedly positive direct Coombs test. However, the absolute reticulocyte count was unexpectedly low, necessitating a bone marrow aspiration. It revealed marked hypoplasia of erythroid lineage that was mainly represented by scattered giant proerythroblasts showing intranuclear inclusions highly suggestive of underlying parvovirus B19 infection (panel A; May-Grunwald Giemsa stain, original magnification 31000). Activated macrophages showing hemophagocytosis were also noted as highlighted on the iron stain preparation (panel B; Perls' Prussian blue stain, original magnification 31000). After common causes of infection and hemolysis were ruled out, the diagnosis was confirmed by serology showing significantly increased anti-human parvovirus B19 immunoglobulin M and by qualitative polymerase chain reaction performed on a bone marrow sample. Therefore, the patient was diagnosed with autoimmune hemolytic anemia (AIHA) associated with pure red cell aplasia (PRCA) caused by parvovirus B19 infection. She was treated with steroids and intravenous immunoglobulin and had a complete recovery.PRCA induced by parvovirus infection is a well-known entity. However, concomitant occurrence of AIHA has been rarely reported in such a context. This association should be considered when a patient presents with a severe acute anemia in the absence of a known cause of shortened erythrocyte lifetime.For additional images, visit the ASH Image Bank, a reference and teaching tool that is continually updated with new atlas and case study images. For more information, visit http://imagebank.hematology.org.