The novel severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) is a highly infectious viral disease that predominantly causes respiratory symptoms. Elevated liver enzymes have been reported during the course of disease and appear to be common. We present a 56‐year‐old woman with a history of decompensated alcoholic cirrhosis who presented with abdominal pain, fever and diarrhoea and was found to have acute on chronic liver failure secondary to SARS‐CoV‐2 infection. The patient was treated with empiric antibiotic and supportive care with subsequent improvement.
In order to determine the relationship between socioeconomic deprivation and nonalcoholic fatty liver disease (NAFLD)/nonalcoholic steatohepatitis (NASH), we retrospectively reviewed the electronic medical records of 1,430 patients in a large tertiary health care network in New York. These patients underwent liver biopsy over a 10-year period and were included in our study if they had evidence of NAFLD/NASH on liver biopsy. Zip codes were used to obtain data necessary to derive the social deprivation index (SDI) from the US Bureau of the Census. The high-SDI group was compared to the low-SDI group. Univariate and multivariate logistic regressions were performed to assess association between socioeconomic factors and NAFLD parameters, including presence of NASH (NAFLD activity score >4), moderate to severe steatosis (>33%), and significant fibrosis (S2-S4). We included 614 patients with NAFLD/ NASH; the median SDI was 31.5. Hemoglobin A1c values were higher in the high-SDI group compared to the low-SDI group (6.46 vs. 6.12, P = 0.02). Socioeconomic factors, such as private versus public health care, percentage being foreign born, percentage without a car, percentage with higher needs (<5 years old and >65 years old), and percentage currently living in renter-occupied and crowded housing units, showed statistically significant associations in predicting NASH. After adjusting for patient age, sex, race, body mass index, and diabetes, we saw a significant association between four or more socioeconomic parameters in predicting NASH (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.099-2.856; P = 0.0190) and six or more socioeconomic parameters in predicting severe steatosis (OR, 1.498; 95% CI, 1.031-2.176; P = 0.0338) but no significant correlation between the number of socioeconomic parameters and significant fibrosis. Conclusion: Greater number of socioeconomic determinants (four or more) are associated with greater severity of NASH. Awareness of NAFLD/NASH needs to be raised in communities with high socioeconomic deprivation. (Hepatology Communications 2022;6:550-560).N onalcoholic fatty liver disease (NAFLD) has a current global prevalence of 24%, with nonalcoholic steatohepatitis (NASH) representing 25% of this population. NAFLD is expected to increase by approximately 30% globally, affecting 100 million people solely in the United States over the next decade. (1)(2)(3)(4) This increase in prevalence of NAFLD will predominately affect areas of growing urbanization and decreasing population size. (4) The increasing clinical impact of NAFLD is already becoming obvious. In the 5-year period between 2012 and 2017, there was greater than a 20% and 15% increase in deaths related to liver cancer and cirrhosis, respectively, in patients initially diagnosed with NAFLD/NASH. (5) In addition, it is well known that people with NAFLD are also at risk for cardiometabolic disease, nonhepatocellular carcinoma, malignancy, lung disease, and diabetes. (6,7) Globally, NAFLD stands as the number one cause of end-stage liver di...
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Metabolic‐associated fatty liver disease (MAFLD) is a growing global problem associated with increasing obesity prevalence. Lifestyle modifications are currently recommended, including weight reduction, exercise, and diet control. This study evaluated the short‐term effect of lifestyle modifications on transient elastography (TE) values in an obese population with MAFLD. Thirty‐two MAFLD patients were recruited for this prospective study and all subjects participated in a 3‐month program of lifestyle modification. Sequential demographic parameters and biochemical tests were compared before and after program completion. Liver fat and fibrosis changes were measured using TE with controlled attenuated parameter (CAP) and liver stiffness measurements (LSM). The mean age was 38.7 years old (10 males). The body weight (88.09 kg vs. 80.35 kg), body mass index (32.24 kg/m2 vs. 29.4 kg/m2), waist (103.19 cm vs. 95.75 cm), and hip circumference (111.67 cm vs. 104.75 cm), and blood pressure (128/78 mmHg vs. 119/71 mmHg) significantly improved before and after the intervention, respectively. Aspartate aminotransaminase (24.06 U/L vs. 18.91 U/L), alanine aminotransaminase (33 U/L vs. 23.72 U/L), creatinine (0.75 mg/dl vs. 0.70 mg/dl), cholesterol (176.41 mg/dl vs. 166.22 m/dl), gamma‐glutamyl transferase (26.59 IU/L vs. 19.81 IU/L), and low‐density lipoprotein cholesterol (115.63 mg/dl vs. 103.19 mg/dl) also improved after the 3‐month intervention. The average CAP significantly decreased after intervention (297.5 dB/m vs. 255.0 dB/m), however, no significant difference in LSM was observed (5.24 kPa vs. 4.82 kPa). The current study suggests that short‐term lifestyle modification can effectively improve hepatic steatosis, and TE may serve as a monitoring tool for therapeutic intervention.
INTRODUCTION: Chronic hepatitis B virus (HBV) infection is a leading cause of liver-related morbidity and mortality affecting 248 million individuals worldwide. Non-alcoholic fatty liver disease (NAFLD) is a common occurrence in chronic HBV infection. It ranges from simple steatosis to active inflammation of nonalcoholic steatohepatitis, and subsequent fibrosis, cirrhosis and an increase risk of hepatocellular carcinoma. Our study aims to assess the causal effect of NAFLD among chronic HBV patients. METHODS: We performed a retrospective chart review of all treated and untreated chronic HBV patients at Sandra Atlas Bass Center for Liver Diseases over the past 5 years. Medical records of study subjects with a diagnosis of NAFLD age ≥ 18 years and <90 years were reviewed. Patients were stratified into the following two groups: (1) mild-moderate steatosis (S0-S2) and (2) severe steatosis (S3). Patients with other co-existing chronic liver diseases were excluded. Clinical data as shown on Table 1 were analyzed. Continuous variables were statistically analyzed with student’s T-test. Categorical variables were analyzed with Pearson’s chi-squared test. RESULTS: We identified 110 patients with HBV infection and NAFLD, of which 68 (61.8%) patients had severe hepatic steatosis. Co-morbidities and ethnicities did not significantly differ among the two studied groups. Patients in the mild-moderate steatosis group had statistically higher HDL level (53.4 vs 46.6mg/dL, P = 0.033) and a lower ALT level (31.0 vs 47.7U/L, P = 0.027) than that observed in the severe steatosis group. Thirty-one percent of patients with severe steatosis were also found to have F2-F4 disease compared to 7% in the mild-moderate steatosis group (P = 0.013). Sixty-three percent of patients in the severe steatosis group required treatment with HBV anti-viral therapy compared to 31% in the mild-moderate steatosis group (P = 0.001). Tenofovir alafenamide (48.2%) was the HBV anti-viral therapy most commonly used. CONCLUSION: Our study showed that patients with severe steatosis tend to have lower HDL but higher ALT and fibrosis stage, and are twice as likely to require anti-HBV therapy. Hepatic steatosis may be an indicator of the severity of chronic HBV infection. Further studies are warranted to understand the correlation between NAFLD and chronic HBV infection.
INTRODUCTION: Cytomegalovirus (CMV) hepatitis most commonly presents with subclinical transaminitis and less commonly with the elevation of alkaline phosphatase (ALP) and total bilirubin (TB). Syphilis hepatitis, on the other hand, generally has a non-specific presentation with a more cholestatic picture. We present a rare case of cholestatic hepatitis from acute CMV infection complicated by syphilis hepatitis. CASE DESCRIPTION/METHODS: A 57-year-old homosexual man presented to the emergency room with complaints of intermittent fever and general malaise for the past two weeks. Blood work showed aspartate aminotransferase (AST) of 235 U/L, alanine aminotransferase (ALT) of 284 U/L, ALP of 940 U/L. TB and coagulation profile were normal. Acute hepatitis A, B, C, Epstein-Barr virus, and herpes simplex virus were ruled out. HIV was negative. Workup for autoimmune hepatitis, primary biliary cholangitis, alpha-1-antitrypsin deficiency, and Wilson’s disease was all negative. Abdominal CT scan with contrast was notable for hepatosplenomegaly without liver lesion. CMV IgM was positive with PCR of 7490 copies/mL, indicating acute CMV infection. The patient subsequently improved without treatment. He presented two months later with worsening liver tests with a peaked ALP of 1981 U/L, TB of 1.6 mg/dL, AST 230 U/L, ALT 195 U/L, associated with the macular rash on his trunk, abdomen, both palms, and soles. Abdominal MRI with contrast showed three < 2cm liver lesions. The patient was subsequently diagnosed with secondary syphilis with rapid plasma reagin (RPR) of 1:16 and confirmatory positive fluorescent treponemal antibody absorption (FTA-ABS). Biopsy of the liver lesions showed granulomatous inflammation with negative immunohistochemistry for CMV which was compatible with clinical syphilis hepatitis. The patient was treated with penicillin G. His rash resolved in 2 months with significant improvement of liver tests. The CMV PCR and RPR were negative with normalization of liver enzymes in 4 months. Follow-up MRI showed resolution of the liver lesions. DISCUSSION: Our patient initially had an atypical presentation of acute CMV hepatitis with cholestatic features. He subsequently developed secondary syphilis associated hepatitis with severe intrahepatic cholestasis and liver lesions. This is, to our knowledge, the first case of CMV hepatitis complicated by syphilis hepatitis. Resolving CMV hepatitis with recurrent elevation in liver tests warrant the workup for possible superimposed liver disease.
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