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Objective: Rare disease Background: Herpes simplex virus (HSV) is a rare cause of hepatitis. HSV hepatitis can be life-threatening due to its rapid progression to liver failure if not treated on time. It affects primarily immunocompromised individuals but can also present in immunocompetent hosts. HSV hepatitis in solid organ transplant recipients usually occurs in the early post-transplant period as fulminant hepatitis. We present a rare case of febrile anicteric HSV2 hepatitis occurring late in the post-transplant period, with only mild elevation in transaminase levels. Case Report: A 60-year-old man presented to the Emergency Department with generalized weakness, chills, and fever for 1 day. His medical history included Crohn's disease, primary sclerosing cholangitis, liver transplantation, and cholangiocarcinoma. Initial laboratory findings revealed leukocytosis. Extensive workup did not reveal a clear etiology of persistent fever. Liver enzymes peaked to aspartate transaminase 198 U/L and alanine transaminase 135 U/L, suggesting possible hepatitis. Liver biopsy showed focal areas of necrosis with vague histiocyte collections. Liver biopsy tissue was positive for HSV2 by polymerase chain reaction; therefore, HSV2 hepatitis diagnosis was made. Intravenous acyclovir was initiated for treatment of HSV2 hepatitis, which resulted with fever resolution within 48 h of initiation and return of liver enzymes to normal levels. Conclusions: This case highlights the importance of having a high suspicion of HSV hepatitis as a rare cause of persistent fevers in immunosuppressed, post-transplant patients even in the late post-transplant period and in the absence of mucocutaneous lesions. Prompt recognition of this disease is crucial to start prompt treatment and decrease mortality. [ABSTRACT FROM AUTHOR]

Case series Patients: Female, 56-year-old • Female, 25-year-old Final Diagnosis: Immune checkpoint inhibitor induced pure red cell aplasia Symptoms: Anemia Clinical Procedure: -- Specialty: Hematology • General and Internal Medicine • Oncolog Objective: Rare disease Background: Immunotherapy is a novel treatment offering an alternative to traditional chemotherapeutic agents for different malignancies. Hematologic adverse reactions (HARs) related to immune checkpoint inhibitors (ICIs) are uncommon. Pure red cell aplasia (PRCA) is a rare hematologic complication of ICI therapy in metastatic melanoma with significant mortality risk despite treatment with steroids or immunosuppressive therapy. For unexplained acute anemia after exclusion of other causes, performing bone marrow biopsy is imperative to diagnose PRCA and rule out involvement of bone marrow by primary tumor. HARs can occur during ICI therapy or even after ICI therapy is stopped. ICI rechallenge, even after the development of HARs, is considered in some patients with good response to treatment of HARs from ICIs. Recurrence of HARs with the same or different type of reaction is seen in some patients. Case Reports: Two cases of ICI-induced PRCA were confirmed on bone marrow biopsy after dual ICI treatment with nivolumab and ipilimumab in metastatic melanoma. In case 2, PRCA was successfully treated with steroids and later rechallenged with single-agent nivolumab, causing mild ICI-induced immune thrombocytopenia, which did not require treatment with steroids. Conclusions: It is crucial to increase clinician awareness of the possibility of PRCA development not only during treatment with ICI but also after finishing treatment with ICI; there is high mortality associated with missing an opportunity to diagnose and treat PRCA on time with favorable results. ICI rechallenge can be considered in patients who showed response to immunotherapy, especially those with limited alternative therapeutic options. [ABSTRACT FROM AUTHOR]

Background: Metformin-associated lactic acidosis (MALA) is a relatively rare adverse effect of metformin therapy. It usually occurs in patients with metformin overdose or in those with underlying acute and/or chronic conditions resulting in impaired lactate metabolism. Among these, patients with acute kidney injury, heart failure, sepsis, and cirrhosis are the most vulnerable to MALA, even in the setting of appropriate therapy. The most common symptoms of MALA include nausea, vomiting, diarrhea, encephalopathy, hypothermia, respiratory failure, and hypotension. Blindness is a dramatic symptom that has been rarely reported with MALA. Case Report: We report a case of 78-year-old woman with history of type 2 diabetes mellitus with nephropathy for which she was treated with metformin and insulin. She developed nausea, non-bloody emesis, and watery diarrhea, which led to dehydration, anion gap metabolic acidosis due to hyperlactatemia, and acute kidney injury (AKI). She was hospitalized for i.v. hydration and further management when she suddenly developed blindness. The diagnostic work-up ruled out central causes and her symptoms resolved briefly after continuous renal replacement therapy (CRRT) was initiated, confirming the diagnosis of MALA. Conclusions: By reporting this case, we wish to increase awareness about MALA symptoms, its diagnosis, and the importance of early recognition and initiation of treatment among clinicians involved in the care of patients with chronic kidney disease (CKD) who take metformin for diabetes mellitus. Although rare, this metformin adverse effect can present dramatically and can be distressing for both patient and treating team. [ABSTRACT FROM AUTHOR]