Drug-induced liver injury (DILI) is one of the leading causes of death from acute liver failure (ALF) in the United States, accounting for approximately 13% of ALF cases in the United States. Selective androgen receptor modulators (SARMs) were first developed to increase muscle mass while avoiding the side effects of conventional androgenic steroids. Although not Food and Drug Administration (FDA) approved, they are widely available online and are consumed to enhance athletic performance. We report a 22-year-old, previously healthy male, who presented with a two-week history of worsening jaundice, nausea, fatigue, pruritus, dark urine, and light stools. He reported taking the SARM, RAD-140, for 16 weeks. Examination showed scleral icterus. The liver panel showed alkaline phosphatase (ALP) 5.3 µkat/L, alanine transaminase (ALT) 1.66 µkat/L, aspartate transaminase (AST) 1.18 µkat/L, direct bilirubin 294 µmol/L, total bilirubin 427.5 µmol/L, and international normalized ratio (INR) 0.9. Viral hepatitis and autoimmune panel were unremarkable. Alpha-1 antitrypsin and ceruloplasmin levels were within normal limits. Bile sludge was seen on ultrasound. Magnetic resonance cholangiopancreatography (MRCP) abdomen showed segmental narrowing of the intrahepatic ducts. Endoscopic retrograde cholangiopancreatography (ERCP) was unremarkable. Liver biopsy showed mixed portal hepatitis, cholestasis, and biliary reactive changes with ceroid-loaded macrophages; a picture consistent with DILI. The patient was treated supportively and discharged with scheduled hepatology follow-up. At the one-month follow-up, his total bilirubin had fallen from a peak of 530 mol/L to 188 mol/L. The diagnosis of DILI can be made based on the timing of exposure and the exclusion of other etiologies. Liver enzymes normalized three to 12 months after product discontinuation. We hope this report will remind primary care physicians of the potential hepatotoxic side effects of muscle-building compounds and encourage them to report suspected DILI to the FDA using the MedWatch system.
Gastric glomus tumor is a rare mesenchymal tumor of the gastrointestinal tract, accounting for approximately 1% of all gastrointestinal soft tissue tumors. We describe a unique case of a 27-year-old female patient who presented with recurrent episodes of overt gastrointestinal bleeding requiring multiple blood transfusions. The patient was diagnosed with a gastric ulcer detected on esophagogastroduodenoscopy (EGD), which was grossly suggestive of an ulcerated gastrointestinal stromal tumor (GIST). Preoperative diagnosis was difficult, requiring laparoscopic robotic-assisted local wedge resection of the gastric mass. Pathological diagnosis and immunohistochemical (IHC) studies were consistent with a glomus tumor. We emphasize that the gastric glomus tumor might present with life-threatening recurrent gastrointestinal hemorrhage. In addition, it might mimic GIST and require surgical resection. Pathological diagnosis and IHC studies are needed to confirm the diagnosis.
In gastrointestinal-variant Lemierre syndrome,
Fusobacterium nucleatum
can cause pylephlebitis and liver abscesses. We report a 62-year-old woman presenting with abdominal pain and altered mental status. Abdominal computed tomography showed hepatic lesions and thrombosis in the superior mesenteric and portal veins. Magnetic resonance cholangiopancreatography showed multiple cystic hepatic masses suspicious for abscess vs metastases. Malignancy workup was unrevealing.
F. nucleatum
grew on both blood and ultrasound-guided liver aspirate cultures. Twelve weeks of antibiotics and anticoagulants resolved her condition. Given the high mortality rates, prompt detection and treatment of gastrointestinal-variant Lemierre syndrome is critical to delivering quality, patient-centered care.
Introduction: Eosinophilic esophagitis (EoE) has been historically more associated with Caucasians. There is currently increased evidence that this disease is underreported in other races especially African American population. In addition, other reports have suggested that EoE may manifest differently in the African American population. The aim of this study is to examine outcomes of EoE based on different racial backgrounds. Methods: Patients hospitalized between 2016 and 2019 who were admitted primarily with EoE or with EoE associated complication (Food impaction, refractory GERD, Dysphagia) and with known EoE diagnosis were identified using International Classification of Diseases Code,10 th Revision Clinical Modification (ICD-10) identified from the Healthcare Cost and Utilization Project databases (HCUP) using the National inpatient sample (NIS). Those patients were stratified according to race. Our primary outcome was in hospital mortality. Secondary outcomes were length of hospital stay (LOS),whether Esophagogastroduodenoscopy (EGD) was performed and time to EGD. Results: After exclusion of other races, a total of 5610 hospitalizations were identified. 4935 (87.97%) patients identified as white while 675 (12.03%) identified as African American. The mean age was 33.1360.79 for the white patients as compared to 32.3962.15 for the African American patients (p50.79). Patients from African American origin had increase Length of stay, 4.04 days (95% CI 3.24-4.84) as compared to 3.14 days (95% CI 2.86-3.42) for white patients, p, 0.001. The mortality rate for white patients was 0.001% as compared to 0% for African American patients (p50.71). 2790 (95% CI 2614.96-2965.04) white patients had EGD as compared to 360 (95% CI 280.26-439.73) African American patients. The median time to EGD was 1 day (IQR51) for white patients and 2 days (IQR52) for African American patients. Log rank test showed x 2 (2) 53.88 and p50.04 Conclusion: Patient from African American descent admitted with EoE appear to have similar mortality as compared to white patients but higher morbidity in the form of longer LOS and longer time to EGD. Further prospective studies are needed to examine these differences and identify possible causes for it.
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