Nodular regenerative hyperplasia (NRH) is a rare cause of non-cirrhotic portal hypertension that should be considered in patients with no risk factors for chronic liver disease or in any unusual presentation of variceal hemorrhage. We present a case of an 82-year-old Chinese female, with a history of previous metastatic sigmoid carcinoma with oxaliplatin use, who presented with melena. A gastroscopy done revealed one column of grade 3 esophageal varix, two columns of grade 2 esophageal varices, and a type 1 gastroesophageal varix with stigmata of recent hemorrhage. Cyanoacrylate glue therapy was performed without any complications. A follow-up computed tomography (CT) imaging of the abdomen did not reveal any significant features of cirrhosis or venous thrombosis, and the decision was made for a transjugular liver biopsy with hepatic venous pressure gradient (HVPG) measurement. The measured HVPG was 6 mmHg, and the liver biopsy showed features consistent with NRH.
Marked elevation of transaminases is rare in typhoid enteric fever. Co-infections with hepatitis A or E, dengue, or other pathogens should be suspected and investigated. Here we report a case of a 29-year-old Bangladesh man who presented with typhoid, hepatitis E and Giardia lamblia complicated by severely deranged liver enzymes. With early institution of antibiotics and active supportive treatment, the patient clinically recovered. The underlying mechanism of co-infection is still not clear. As clinicians, comprehensive workup for potential pathogens helps expedite diagnosis, especially in patients from endemic areas or patients who deteriorate rapidly. Current diagnostic methods, treatment modalities and preventive measures still need to be improved in the future.
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