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Hepatocellular carcinoma (HCC) is potentially fatal complication affecting patients with primary biliary cholangitis (PBC). The incidence of HCC is 13 per 1000 person-years in patients with PBC cirrhosis, but much lower at 2.7 per 1000 person-years among patients with PBC without cirrhosis. Risk factors for the development of HCC in PBC include the presence of advanced fibrosis or cirrhosis and male sex, with some studies suggesting that treatment with ursodeoxycholic acid (UDCA) and UDCA response may reduce risk.

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.

Infectious jaundice has been with mankind for thousands of years. Hepatitis B, hepatitis C and hepatitis D are all transmitted through contact with blood or other bodily fluids. There can also be vertical transmission from mother to child. All three viruses can result in acute viral liver disease or chronic viral disease leading to cirrhosis. These viruses are also notorious for causing the acute decompensation of pre-existing chronic liver disease. In that last situation, the prognosis of acute on chronic liver disease is worse than a patient who has decompensation of cirrhosis. In the present chapter we will summarize the history and epidemiology of each virus. The clinical course of acute or acute on chronic liver disease are reviewed as well as the prognosis of each presentation. The availability of therapy for treatment will be discussed along with any possible strategies for prevention.

Vitamin D has been postulated to play a role in colonic carcinogenesis by modulation of apoptosis and inhibition of angiogenesis. However, data supporting this theory are conflicting, and most studies include only Asians and Caucasians. This retrospective study aims to determine whether there is a correlation between an increased total vitamin D level and a lower incidence of carcinomatous polyps in a multi-race but predominantly Hispanic population in East Harlem, New York City. A case–control study was conducted involving all patients who underwent colonoscopy at Metropolitan Hospital Center in 2011 and who also had serum total vitamin D levels taken within 1 month before or after the date of colonoscopy. Total vitamin D levels and the presence of carcinomatous polyps were the main variables studied. Colonic polyp-positive (CP+) samples were designated as the case group, while colonic polyp-negative (CP−) samples were assigned to the control group. Logistic regression analysis was used to estimate odds ratio at a 95 % confidence interval. Adjusted variables were chosen a priori and included age, sex, race, smoking and alcohol history, body mass index, and folate and aspirin use. We identified 1,640 patients who underwent colonoscopy from January 1 to December 31, 2011. Of these, 136 also had a vitamin D serum level drawn within 1 month before or after the colonoscopy. Forty-three were CP+ and assigned to the cases group, and 93 were CP− and assigned to the control group. Thirty-five percent of the sample had total serum vitamin D levels of

Hepatitis C infection and its treatment have been associated with extrahepatic manifestations, including different skin conditions. Over the past decades, a greater number of drugs have been implicated as triggers for drug-induced subacute cutaneous lupus erythematosus. We report a case of a 42-year-old Hispanic man who developed a forehead violaceous rash during treatment with pegylated interferon alpha-2a as part of his therapy against hepatitis C infection that subsequently resulted to be subacute cutaneous lupus erythematosus. The skin lesion improved with discontinuation of medication and some topic therapy.

Pulmonary aspergillosis presents with a variety of clinical forms including invasive pulmonary aspergillosis, chronic necrotising aspergillosis, aspergilloma, chronic cavitary pulmonary aspergillosis and allergic bronchopulmonary aspergillosis. Haemoptysis is a devastating complication of pulmonary aspergillosis and a common indication for surgery. We report a case of a 54-year-old man with a history of pulmonary tuberculosis and diabetes mellitus, who presented with productive cough and haemoptysis for 2 months. Chest CT revealed a 30 mm diameter soft tissue mass in the upper lobe of the right lung. Haemoptysis subsided with conservative measures, but 2 weeks later the patient developed a new episode of persistent haemoptysis, which was only partially controlled with bronchial arterial embolisation. He underwent right upper and middle lobectomy. Histology examination confirmed the presence of a fungal cavitary lesion. The patient was started on voriconazole, and recovered with no recurrence at 18 months follow-up.

Cholesterol crystal embolism can be spontaneous or iatrogenic, and it can involve any organ of the gastrointestinal tract, presenting with common gastrointestinal symptoms such as bleeding, perforation, obstruction, and inflammation. It is therefore considered the “great masquerader,” requiring a high level of suspicion because the condition is associated with increased morbidity and mortality. We present a 69-year-old man who presented with gastrointestinal bleeding and azotemia. He was found to have cholesterol crystal embolization in the kidney and a duodenal leiomyoma, the latter being an uncommon site to embolize.

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.

Sy, Alexander M Fernandez, Gina S Williams, Susan Bergasa, Nora V Chaudhari, Shobhana United States J Am Geriatr Soc. 2011 Nov;59(11):2172-3. doi: 10.1111/j.1532-5415.2011.03650.x.

A relationship between hepatocellular carcinoma and chronic lymphocytic leukaemia has been reported. This is a case of a 75-year-old woman with stable chronic lymphocytic leukaemia, not on treatment with an increased activity of serum alkaline phosphatase and negative liver disease work up. A liver biopsy revealed leukaemic infiltration without evidence of cirrhosis or fatty liver. Four years later, she presented with a rapidly progressive liver mass which was diagnosed as hepatocellular carcinoma histologically.

A 59-year-old Hispanic woman with no significant medical history presented with a stroke while travelling on a South East Asian cruise. Work up included an echocardiogram showing a large multilobulated aneurysm (arrow) with a base measuring 2.2 cm (green line) with several smaller lobulations in the parasternal long-axis view ( Panel A …