Liver involvement associated with dengue infection in adults in Vietnam

Globally, the number of adults hospitalized with dengue has increased markedly in recent years. It has been suggested that hepatic dysfunction is more significant in this group than among children. We describe the spectrum and evolution of disease manifestations among 644 adults with dengue who were prospectively recruited on admission to a major infectious disease hospital in southern Vietnam and compare them with a group of patients with similar illnesses not caused by dengue. Transaminase levels increased in virtually all dengue patients and correlated with other markers of disease severity. However, peak enzyme values usually occurred later than other complications. Clinically severe liver involvement was infrequent and idiosyncratic, but usually resulted in severe bleeding. Chronic co-infection with hepatitis B was associated with modestly but significantly increased levels of alanine aminotransferase, but did not otherwise impact the clinical picture.     

Risk factors and clinical features associated with severe dengue infection in adults and children during the 2001 epidemic in Chonburi, Thailand

OBJECTIVES: Dengue haemorrhagic fever (DHF) is an important cause of morbidity in South-east Asia and used to occur almost exclusively in young children. In recent years, there has been a progressive shift in age-distribution towards older children and adults. We investigated an outbreak in 2001 in both children and adults, in an endemic area of Thailand. METHODS: Retrospective study of 347 patients with serologically confirmed dengue infection admitted to Chonburi Hospital during an epidemic in 2001. RESULTS: A total of 128 (37%) patients had dengue fever (DF) and 219 (63%) had DHF. Patients with DHF were significantly older than patients with DF (11 years vs. 8 years). Clinical bleeding was noted in 124 individuals, both with DF (n = 24) and DHF (n = 100), and significantly more frequently in adults. Twenty-nine (13.2%) of all DHF cases were caused by primary infection. Secondary dengue infection was associated significantly with the development of DHF in children, OR (95% CI) = 3.63 (1.94-6.82), P < 0.0001, but not in adults, OR (95% CI) = 0.6 (0.02-6.04), P = 1. Unusual clinical manifestations were observed in 23 patients: three presented with encephalopathy and 20 with highly elevated liver-enzymes. In the latter group, four patients were icteric and nine had gastrointestinal bleeding. CONCLUSION: These results indicate that DHF in South-east Asia is common in both children and adults. In dengue-endemic countries, dengue should be considered as a differential diagnosis in patients with clinical gastrointestinal bleeding in association with increased liver enzymes.     

Clinical features of acute renal failure associated with hepatitis A virus infection

Summary. Acute hepatitis A (AHA) is one of the most common infectious diseases; it is usually a self‐limiting disease affecting the liver. Although extrahepatic manifestations are not common, some cases have been reported associated with acute renal failure. We reviewed the clinical features of patients with AHA complicated by acute renal failure (ARF group) and compared them with patients with noncomplicated AHA (non‐ARF group). The medical records of 208 consecutive patients with AHA who were diagnosed between January 2003 and October 2008 were reviewed. We identified 15 patients (7.2%) with ARF associated with AHA. There were no differences between the ARF and non‐ARF group with regard to gender and age. The peak value of alanine aminotransferase (ALT) (median: 6060 IU/L vs 1792 IU/L, P < 0.001), prothrombin time (PT) (International normalized ratio, median 1.72 vs 1.10, P < 0.001), and total bilirubin level (median: 9.6 mg/dL vs 6.3 mg/dL, P = 0.04) were significantly higher in the ARF than in the non‐ARF group. Twelve patients (80%) recovered completely with haemodialysis (seven patients, 46.7%) or only conservative management (five patients, 33.3%), while one patient underwent liver transplantation because of fulminant hepatic failure, and two patients died because of fulminant hepatic failure. There were no deaths among patients with noncomplicated AHA in the non‐ARF group. Five patients underwent kidney biopsy; two patients were diagnosed with acute tubular necrosis, two patients with acute interstitial nephritis with IgA nephropathy and one patient with acute tubulointerstitial nephritis. All patients in the ARF group had microscopic haematuria and proteinuria (100%vs 31.1%, P < 0.001). Urine sodium levels were more than 10 mEq/L in 10 patients. The findings of high urinary sodium concentrations, microscopic haematuria and proteinuria did not support the diagnosis of hepatorenal syndrome (HRS). Patients with AHA with ARF had higher ALT levels, more prolonged PTs, and higher total bilirubin levels. The prognosis for these patients was poorer than for those without ARF. However, the patients with ARF and nonfulminant AHA had recovered with proper treatment and should not be confused with patients that have HRS.     

Characteristics and outcomes of adults with cytomegalovirus-associated thrombocytopenia: a case series and literature review

Cytomegalovirus (CMV) is a ubiquitous virus that infects people worldwide. CMV is known to trigger thrombocytopenia, but this association is probably underdiagnosed since CMV infection in healthy adults is usually either asymptomatic or causes only mild symptoms. A systematic literature review was carried out and yielded 23 publications that reported 25 patients. All haematology centres in Israel were searched for adult immunocompetent patients with CMV-associated thrombocytopenia, and five new cases were identified. The median age of the combined 30 patients was 33 years (range 18–80), 73% were men, 77% presented with CMV-related symptoms, 48% had enlarged spleens, 95% had atypical lymphocytes in peripheral blood and 68% had elevated transaminase levels. The response rate to first-line steroid-containing regimens was only 31%, whereas 11 patients who were treated with an anti-CMV agent had a response rate of 82%. Moreover, four patients received thrombopoietin receptor agonists (TPO-RA) to which three (75%) responded. Taken together, these distinctive features of a case with thrombocytopenia should alert to CMV infection as the source. While steroids were effective in less than one-third of the cases, both anti-CMV therapy and TPO-RA exhibited excellent efficacy, suggesting that those agents should be introduced earlier in the therapeutic course.     

Useful clinical features and hematological parameters for the diagnosis of dengue infection in patients with acute febrile illness: a retrospective study

Background

Dengue infection patients are presented with acute febrile illness. Clinical presentations may mimic other infections. The serology for definite diagnosis is costly and inaccessible in many hospitals. We sought to identify the clinical features and hematologic parameters from a complete blood count (CBC) which distinguish dengue infection from other causes.

Methods

This was a retrospective single center study from Chiang Mai University Hospital. All patients who presented with acute fever between September 2013 and July 2015 were included. The diagnosis of dengue infection must be confirmed by serology. The control groups were patients who presented with acute febrile illness without localizing signs. Clinical data and CBC results were reviewed and compared. The Chi-square test was used to compare categorical variables. The CBC parameters were analyzed using the linear mixed model.

Results

One hundred and fifty-four dengue and 146 control patients were included. Headache, nausea, loss of appetite and bleeding diathesis were significantly symptoms in dengue patients (p?<?0.05). There was some diversity in the the CBC in the dengue patients compared to the control group. Moreover, this study also identified the day of fever which these parameters were statistically significant. The dengue group had higher hemoglobin and hematocrit from day 3 to day 10 (p?<?0.001), lower white blood cell count from day 1 to day 10 (p?<?0.001), lower platelet count from day 3 to day 10 (p?<?0.001), higher monocyte on day 1–4 (p?<?0.001), higher atypical lymphocyte percentage on day 5–9 (p?<?0.001) and higher eosinophil percentage on day 9–10 (p?=?0.001). Furthermore, the neutrophil to lymphocyte percentage ratio of dengue group was >?1 on the first 5 days then reversed on day 6 to Day 9 but in non-dengue group, the ratio was always >?1.

Conclusion

We identified important clinical features and CBC parameters to differentiate dengue patients from other patients who had acute febrile illness from other causes. This identification could be done in local hospitals to give an accurate diagnosis, enabling further investigation to be tailored and treatment commenced earlier.

     

Clinicopathologic features and clinical outcomes of intravenous leiomyomatosis of the uterus: A case series

Rationale:Intravenous leiomyomatosis (IVL) is a rare and special type of smooth muscle tumor originating in the uterus. It is classified as a benign disease according to its histological features but shows the behavioral characteristics of a malignant tumor. It is easily misdiagnosed and recurrent. The purpose of this study was to retrospectively analyze clinicopathological data of 25 cases of IVL in order to enhance clinicians’ understanding of this rare disease.Patient concerns:We screened and identified 25 cases of IVL at our hospital from October 2013 to January 2020. Five patients had tumors.Diagnoses:The diagnosis in each case was pathologically confirmed after surgical treatment.Interventions:All patients were managed surgically. Although the surgical procedures were different, the surgical approach was geared towards achieving complete excision. Three patients received hormonal therapy with gonadotropinreleasing hormone agonists after surgery.Outcomes:We retrospectively reviewed all medical records and analyzed the clinicopathologic features and clinical outcomes of this disease as well as the correlations between the clinical features and risk of recurrence. Neither the symptoms nor the preoperative imaging results were suggestive of IVL in any of the cases. Except for two patients who were lost to follow-up, twenty-three patients who were followed up are still alive. Three patients experienced a recurrence.Lessons:The clinical manifestations and ultrasound images of IVL in the early stages are not typical; thus, IVL is easily misdiagnosed as uterine leiomyoma. Radiologists, pathologists, and surgeons should have a thorough understanding of IVL and a high index of vigilance for IVL in clinical practice. Surgery should always be aimed at achieving complete tumor excision. Patients with large lesions (≥7 cm) and lesions extending to the broad ligament may have an increased risk of recurrence. Early detection, diagnosis, and treatment are very important; once the diagnosis is confirmed, regular follow-ups are crucial.     

Influenza a viral infection associated with acute renal failure

The clinical and laboratory findings in four cases of acute renal failure following the onset of influenza A viral Infection (Port Chalmers/1/73) are presented.Although the pathophysiologic mechanisms affecting the kidney in these cases varied, the ensuing renal failure in each patient was severe. Findings suggestive of acute myoglobinuria developed in one patient, and disseminated intravascular coagulation (DIC) occurred in another.The role of viruses in the pathogenesis of renal disease is reviewed. Despite inconclusive evidence that the influenza virus can cause human renal disease, the secondary pathways that can be triggered by viral infections may be even more significant in producing various degrees of renal dysfunction. The occurrence of renal failure during an episode of influenza represents a serious complication which may influence significantly the morbidity and mortality of patients with this viral infection.     

Prevalence of dengue infection in north Indian children with acute hepatic failure

Hepatic manifestations of dengue viral infection are well known and cases of acute hepatic failure (AHF) with evidence of dengue infection are reported.Objectives: To study the role of dengue infection in AHF presenting to hospital.Methods: Setting: Pediatric wards of a teaching hospital in northern India. Subjects: Consecutive children hospitalized with AHF over a 3 month period in 2006. Clinical and laboratory details of subjects were charted. ELISA tests for dengue IgM were done in all patients using commercial kits. Real time PCR assays for dengue genome were done in randomly chosen subjects from those testing positive and negative for IgM. A PCR positive case was considered as definite dengue infection, while those who were only IgM positive were considered as ‘probable’ dengue.Results: Between July and September 2006, 27 patients were enrolled. Thirteen were unequivocally positive for dengue IgM. A random sample of 7 IgM positive and 3 IgM negative patients was tested by PCR, of which 4 IgM positive and one IgM negative patients were PCR positive. Prevalence of definite dengue infection in AHF was therefore 5/27 or 18.5%. No significant differences were observed in clinical and laboratory features of dengue and nondengue aHF.Conclusions: Dengue infection should be considered in the etiology of AHF in this part of the world. Clinico-laboratory differentiating features of dengue AHF should be studied in a larger sample of patients.     

The benign nature of acute dengue infection in hospitalized older adults in Singapore

ObjectivesIn Singapore, dengue primarily affects adults. This study aimed to determine if older dengue patients in Singapore have greater morbidity and mortality.MethodsAll laboratory diagnosed dengue patients admitted to Tan Tock Seng Hospital in 2004 were retrospectively reviewed. Cases were re-classified into dengue fever and dengue hemorrhagic fever based on World Health Organization criteria. Demographic, clinical, laboratory, and outcome data of patients aged ≥60 years and <60 years were collected.ResultsOf 1971 laboratory confirmed dengue cases, 66 were aged ≥60 years. Older patients were significantly less likely to be male (44% vs. 64%), and more likely to have diabetes (17% vs. 2%), hypertension (48% vs. 4%), ischemic heart disease (6% vs. 0.1%), hyperlipidemia (18% vs. 1%), and secondary dengue infections (64% vs. 34%). Clinical features were similar except older patients were significantly less likely to report fever (92% vs. 99%), or have leukopenia (32% vs. 51%) or hemoconcentration (0 vs. 5%) on admission. Older patients had similar dengue hemorrhagic fever, bleeding, hypotension, severe thrombocytopenia, and elevated transaminase rates. Length of hospital stay, risk of intensive care unit admission, and outcome of death were not statistically different.ConclusionsDespite greater co-morbidity and secondary dengue infection, older dengue patients in Singapore did not have greater morbidity or mortality.     

Opportunistic infection in patients with acute liver failure

Background

Treatment with systemic corticosteroids is often used for acute liver failure (ALF), but this has increased the number of profoundly immunocompromised patients and cases of opportunistic infection.

Methods

Between January 2007 and December 2012, all patients (n = 51) referred to the Chiba University Hospital for treatment of ALF were studied. Patients with prothrombin activity of 40 % or less of the standardized values were defined as having ALF. Patient age, sex, cause of ALF, alanine aminotransferase and total bilirubin levels, prothrombin activity and total amount of corticosteroid were analyzed to determine the factors associated with the occurrence of opportunistic infection.

Results

Opportunistic infections occurred in 21.6 % (n = 11) of ALF patients. Thirty-five patients underwent systemic corticosteroid therapy, and 31.4 % of those patients showed opportunistic infections. Cytomegalovirus (n = 9, 81.8 %) and Pneumocystis jiroveci (n = 6, 54.5 %) were the microorganisms frequently suspected as the causes of opportunistic infection. In 7 (63.6 %) of the 11 cases of opportunistic infection, 2 or more species of microorganism were detected. Seven patients (63.6 %) with opportunistic infection were cured by treatment. Cox regression analysis for the patients who underwent systemic corticosteroid therapy steroid treatment revealed that age over 52 years (compared to younger patients: odds ratio = 9.62, 95 % confidence interval = 1.22–76.9) was only the predictive factor for the occurrence of opportunistic infection.

Conclusion

Opportunistic infections are not rare in ALF patients, and the appropriate diagnosis and treatment of these infections are critical during ALF treatment.     

The clinical differences between dengue and scrub typhus with acute respiratory failure in southern Taiwan

Background

For both dengue and scrub typhus, acute respiratory failure (ARF) is a serious complication. The present study was carried out in order to investigate the clinical courses and outcomes of adult dengue and scrub typhus patients with ARF, and to identify the clinical differences between adult dengue and scrub typhus patients with ARF.

Methods

We conducted a retrospective study of the serologically confirmed adult dengue or scrub typhus patients admitted between 1998 and 2008 at Kaohsiung Chang Gung Memorial Hospital. A total of 980 dengue and 102 scrub typhus adult patients were included in our study.

Results

Eighteen of the 980 adult dengue patients and 8 of the 102 adult scrub typhus patients had ARF. There were significant differences that existed for eschar (P?=?0.001; dengue 0%; scrub 62.5%), cough (P?=?0.016; dengue 55.6%; scrub typhus 100%), white blood cell (WBC) count [P?=?0.026; dengue 7.40?±?5.74; scrub typhus 11.84?±?4.95 (×10³/??L)], platelet count [P?=?0.008; dengue 42.2?±?33.9; scrub typhus 104.1?±?93.3 (×10⁹/L)], prothrombin time (PT) [P?=?0.007; dengue 12.82?±?1.36; scrub typhus 10.74?±?0.98 (s)], activated partial thromboplastin time (APTT) [P?=?0.002; dengue 50.81?±?10.08; scrub typhus 37.44?±?4.06 (s)], blood urea nitrogen (BUN) [P?P?P?=?0.027; dengue 2.9?±?1.3; scrub typhus 5.4?±?2.6 (days)], and ventilator duration [P?=?0.022; dengue 9.4?±?14.0; scrub typhus 14.8?±?10.4 (days)] between both groups.

Conclusions

This study provides relatively rare data regarding the clinical differences between adult dengue and scrub typhus patients with ARF.     

Clinicopathologic features and treatment outcomes of patients with fibrillary glomerulonephritis: A case series

Fibrillary glomerulonephritis (FGN) is a diverse glomerular disease with poor renal prognosis. The optimal therapeutic approach remains undetermined, as treatment outcomes vary across different studies.We retrospectively reviewed the medical data of 10 patients diagnosed with biopsy-proven FGN at our center between 2004 and 2019. Clinical and histological features, as well as therapeutic regimens and treatment response, are reported.The patients were predominantly men (2.5/1 men-female ratio) with a mean age at diagnosis of 46.5 years (IQR: 41.5-59.5). The median proteinuria and creatinine levels at presentation were 2.55 g/day (IQR: 0.4-8.9) and 1.35 mg/dl (IQR: 0.94–1.88), respectively. Four out of 10 patients presented with nephrotic syndrome, 5 patients with nephritic syndrome and 1 with isolated microscopic hematuria. Light microscopy showed mesangial proliferative (n = 7), membranoproliferative-like (n = 2), and diffuse sclerosing patterns (n = 1). Rituximab was used in 7/10 patients, either as monotherapy (n = 3) or combined with cyclophosphamide and corticosteroids (n = 4). Patients who were treated with immunosuppression had higher median levels of creatinine (1.40 mg/dl) and proteinuria (3.5 g/d) compared to those who received supportive treatment alone (0.94 mg/dl and 0.6 g/d, respectively). After a median follow-up of 30 months (IQR:18–66.5), 4 out of 7 patients (57%) treated with immunosuppression achieved a clinical response, 1 had persistent renal dysfunction and 2 patients progressed to end-stage renal disease.The present case series extends the existing literature on the clinical features and outcomes of FGN, as well as the use of rituximab-based regimens for the treatment of the disease. Further research is needed to establish the proper management of the disease.     

Fatal acute liver failure associated with pirprofen. Report of a case and a review of the literature

This report is about a 71-yr-old woman who suffered from acute liver failure, induced by the nonsteroidal antiinflammatory drug, pirprofen. She presented with jaundice 6 weeks after starting treatment with 800 mg pirprofen daily. She is the fifth patient described in the literature to die from pirprofen-induced hepatotoxicity.     

Epidemiology and outcomes of acute liver failure in Australia

BACKGROUND Acute liver failure(ALF) is a life-threatening syndrome with varying aetiologies requiring complex care and multidisciplinary management. Its changing incidence, aetiology and outcomes over the last 16 years in the Australian context remain uncertain.AIM To describe the changing incidence, aetiology and outcomes of ALF in South Eastern Australia.METHODS The database of the Victorian Liver Transplant Unit was interrogated to identify all cases of ALF in adults( 16 years) in adults hospitalised between January 2002 and December 2017. Overall, 169 patients meeting criteria for ALF were identified. Demographics, aetiology of ALF, rates of transplantation and outcomes were collected for all patients. Transplant free survival and overall survival(OS) were assessed based on survival to discharge from hospital. Results were compared to data from a historical cohort from the same unit from 1988-2001.RESULTS Paracetamol was the most common aetiology of acute liver failure, accounting for50% of cases, with an increased incidence compared with the historical cohort(P= 0.046). Viral hepatitis and non-paracetamol drug or toxin induced liver injury accounted for 15% and 10% of cases respectively. Transplant free survival(TFS)improved significantly compared to the historical cohort(52% vs 38%, P = 0.032).TFS was highest in paracetamol toxicity with spontaneous recovery in 72% of cases compared to 31% of non-paracetamol ALF(P 0.001). Fifty-nine patients were waitlisted for emergency liver transplantation. Nine of these died while waiting for an organ to become available. Forty-two patients(25%) underwent emergency liver transplantation with a 1, 3 and 5 year survival of 81%, 78% and72% respectively.CONCLUSION Paracetamol toxicity is the most common aetiology of ALF in South-Eastern Australia with a rising incidence over 30 years. TFS has improved, however it remains low in non-paracetamol ALF.