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Dietary supplements are unregulated medications that can lead to serious liver injury. Despite this, many people take vitamin supplements believing they are safe because they do not require prescriptions. We are reporting a case of an African American man who took large doses of vitamin supplements leading to noncirrhotic portal hypertension. The case highlights the importance of detailed history taking to diagnose and treat patients properly.

Commonly reported complications of hepatic cysts are spontaneous hemorrhage, rupture into the peritoneal cavity, infection and compression of the biliary tree however cardiac complications are not commonly reported. We are presenting a case of a large liver cyst presenting with right atrial and ventricular inflow tract impingement resulting in cardiac symptoms. A 68 year-old Hispanic female presented with one month of fatigue and shortness of breath after household work and walking less than one block, right upper quadrant pain and weight loss. She had history of multiple hepatic cysts for more than 12 years, well-controlled diabetes and hypertension. Examination of the heart revealed tachycardia with regular heart sounds. There were no murmurs. She had tenderness in her right upper quadrant on palpation and an enlarged smooth liver. Rest of physical examination was unremarkable. CT scan of the abdomen showed multiple non-enhancing liver cysts in both lobes, with the largest measuring 12 x 15 x 17 cm which was significantly increased from her baseline of 7 x 8 x 10 cm in 2003. Echocardiogram showed normal left ventricular ejection fraction, grade 1 diastolic dysfunction and a hepatic cyst impinging RA and RV inflow tract. She had successful laparoscopic enucleation of liver cyst and subsequent relief from tachycardia, fatigue and shortness of breath. In conclusion, this case illustrates that hepatic cysts may become symptomatic after remaining quiescent for an extended period. They may present with unusual symptoms and clinicians should be mindful of rare complications, such as in this case.

A 52-year-old woman presented with a 1-week history of recurrent fevers and joint pains accompanied by abdominal and low back discomfort. She has a history of hypoparathyroidism and is on calcium supplements. Physical examination revealed fever and tachycardia. The rest of the examination was normal. Laboratory tests showed newly increased transaminase activity. Serum bilirubin and prothrombin time were normal. She was admitted for evaluation of acute hepatitis. Serology for hepatitis A, B, C and HIV were negative. Her serum acetaminophen and alcohol were undetected. Abdominal imaging was normal. Cultures were sterile. Additional tests for uncommon viral hepatitis included herpes simplex virus, cytomegalovirus and Epstein-Barr virus. Liver biopsy revealed non-specific inflammation. Subsequently, cytomegalovirus serology showed an IgM positive and negative IgG titre. Cytomegalovirus DNA qualitative PCR was also positive. No antiviral medication was given. She continued to have intermittent daily fever but reported no associated symptoms. She was discharged 9 days after admission in stable condition per her request with the advice to follow-up in the clinic in 1 week. Her serum hepatic profile returned to normal and she reported no more episodes of fever. Repeated titres of cytomegalovirus serology showed seroconversion.

Osteoarticular infections caused bySalmonellaare rare. The rates of osteomyelitis and septic arthritis due toSalmonellaare estimated to be less than 1% and 0.1%-0.2%, respectively (Kato et al., 2012).Salmonella entericaserotype Choleraesuis is anontyphoidal Salmonella, highly pathogenic in humans, usually causing septicemic disease with little or no intestinal involvement. Serotype Choleraesuis accounts for a small percentage of published studies ofSalmonellainfections in the United States. It is not commonly reported in joint fluid and bones in contrast to serotype Enteritidis and Typhi, where a considerable number of cases have been published. Chen et al. in Taiwan found that 21% of bacteremic patients with this infection subsequently develop focal infections such as septic arthritis, pneumonia, peritonitis, and cutaneous abscess (Chen et al., 1999, Chiu et al., 2004). In contrast, our patient presented with localized osteoarticular infection withSalmonella enterica serotype Cholerasuis, but without evidence of bacteremia.