Hepatic injury due to dietary and herbal supplements can often share similar clinical characteristics with autoimmune hepatitis (AIH). Sambucus species, commonly known as elderberry, have been used in traditional medicine for centuries to prevent and treat respiratory problems. Although there are no clear reports on the association of elderberry with AIH or drug-induced hepatitis, there have been concerns about negative health manifestations linked to elderberry and the overproduction of inflammatory cytokines. In this article, we discuss a case of a patient who developed autoimmune hepatitis while on long-term elderberry-containing supplements and a probable association between the two.

Serum-ascites albumin gradient (SAAG) is an initial and useful measure to differentiate causes of ascites. High gradient ascites (SAAG >1.1 g/dL) is one of the important features of heart failure. Low gradient ascites in heart failure is relatively rare and needs additional workups to rule out other serious causes, such as malignancy and infection. We herein report a case of a 42-year-old female with low-SAAG ascites from worsening congestive heart failure, which was confirmed to be portal hypertension-originated by triphasic abdominal computed tomography.

Giant cell arteritis (GCA) is an inflammatory vasculitis that typically affects the elderly, preferentially involving large and medium-sized arteries and can potentially cause irreversible loss of vision. Early diagnosis and treatment are necessary to prevent this dreaded complication. Temporal artery biopsy has been the gold standard test in diagnosing GCA, however, false negative results due to presence of skip lesions, restricted inflammation, and early initiation of steroids have limited its diagnostic significance. We report a case of a 67-year-old female with headache, blurry vision, posterior scalp tenderness, feeble left temporal artery pulse on a physical exam with normal inflammatory markers. Temporal artery biopsy showed disruption and reduplication of internal elastic lamina without any evidence of giant cells or inflammatory cells. Owing to high clinical suspicion, fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) was further done which revealed mildly increased uptake in the thoracic aorta, consistent with a diagnosis of large vessel vasculitis.

Ventriculitis is the inflammation of the ependymal lining of the ventricles in the brain which usually occurs as a complication of meningitis, intraventricular devices, intracranial surgery, or brain abscess. Common clinical features include fever, altered mental status, headache, and neck rigidity. Some commonly associated organisms are Streptococcus, gram-negative Bacillus, Staphylococcus, and Meningococcus. Here, we report the case of a 57-year-old female presenting with fever, headache, and altered mental status, along with positive physical examination findings of Kernig's and Brudzinski's signs without any focal neurological deficits. Cerebrospinal fluid analysis findings were consistent with bacterial infection with neutrophilic leukocytosis, high protein, and low glucose. The blood culture was positive for Streptococcus pneumoniae. Magnetic resonance imaging was negative for enhancement of the meninges but showed fluidfilled layering in the ventricles consistent with pyogenic ventriculitis. The patient improved clinically within three days of initiation of empiric antibiotics.

Nivolumab is a humanized monoclonal anti-programmed cell death receptor-1 (PD-1) antibody that has been authorized for use in the treatment of advanced malignancies. Cutaneous reactions are the most common immune-related adverse events reported with anti-PD-1 agents, and they range broadly from mild localized reactions to rarely severe or life-threatening systemic dermatoses. The occurrence of Steven-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) with nivolumab use is an exceedingly rare phenomenon that was only documented in a handful of cases in the current literature, but it deserves careful attention as SJS/TEN may be associated with fatal outcomes. We present a case of nivolumab-induced SJS/TEN in a middle-aged female patient with metastatic gastric adenocarcinoma that was successfully treated with immunosuppressive therapy and supportive care. Prompt recognition of SJS/TEN with discontinuation of nivolumab is warranted when SJS/TEN is suspected clinically. Multidisciplinary management in a specialized burn unit is the key to improving outcomes of SJS/TEN.

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Lithium is a commonly used medication for mood stabilization and a well-known cause of nephrogenic diabetes insipidus (DI). Coexistent psychogenic polydipsia with nephrogenic DI is uncommon, and its management is challenging due to the wide variation in serum sodium based on fluctuations in water intake. Here, we describe the case of a 56-year-old male with psychogenic polydipsia and nephrogenic DI which manifested in wide swings of serum sodium over a short interval. He initially presented with hyponatremia with low urine osmolality consistent with psychogenic polydipsia. His serum sodium began to improve after free water restriction. However, later in the course, he developed an increase in serum sodium levels and polyuria with persistent low urine osmolality consistent with DI.