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Severe hepatocytolisis syndrome - a challenge in medical therapy of Cushing’s disease

ABSTRACT

Introduction Cushing’s disease is a rare endocrine disorder characterized by persistent hypercortisolism due to excessive, autonomous ACTH secretion by a pituitary adenoma. Transsphenoidal adenomectomy is the main therapeutic option in Cushing’s disease. When imaging studies are unable to demonstrate an obvious pituitary mass complete tumor resection is difficult and often encumbered by risk of relapse. Medical therapy is a second-line option or the first-line treatment for patients with high surgical risk, incomplete surgical resection or relapse. Rarely classic clinical manifestations limit the selection of medical therapy for Cushing’s disease. Case presentation We present the case of a male patient with Cushing’s disease complicated with diabetes mellitus and severe hepatocytolisis syndrome with no visible pituitary adenoma on MRI studies. In the absence of technical equipment petrosal sinus sampling could not be performed in order to improve surgery outcome

Conclusion The presence of unbalanced diabetes and severe hepatocytolisis syndrome made it impossible to use steroidogenesis inhibitors (mitotane, ketoconazole, metyrapone, etomidate) or inhibitors of ACTH secretion as pasireotide that represent a new option in achieving control of hypercortisolism

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Leptospirosis - A Case Report

Abstract

Leptospirosis is a spirochaetal zoonosis, with a broad spectrum of clinical manifestations, ranging from mild (febrile illness) to fulminant forms (systemic disease with jaundice and kidney failure – Weil's disease).

We present the case of a 62 year old patient, with no personal pathological incidents, brought to the emergency room for fever, chills, myalgia, nausea, vomiting, abdominal pain, for 14 days, with jaundice, shortness of breath, and confusion for 72 hours. Clinical examination revealed fever, confusion, jaundice, tachypnoea, tachycardia, irregular heart rhythm, hypotension, anuria, hepatomegaly, no clinical signs of liver cirrhosis or flapping tremor. Laboratory tests revealed leucocytosis with neutrophilia, hepatic cytolysis, renal failure, rhabdomyolysis, while the imagistic investigations were normal. Serological tests were performed for viral, drug induced hepatitis, autoimmune diseases, other infectious diseases (Elisa and ultramicroscopic agglutination tests were positive for leptospirosis). Later, the patient's condition worsened, resulting in intubation and mechanical ventilation, persistence of febrile syndrome and jaundice, bilateral lower limb petechiae with hepatic encephalopathy. Broad spectrum antibiotics (Ceftriaxone and Penicillin G), dialysis, hydroelectrolytic rebalancing, Dopamine support, antiarrhythmic drugs were administered, and the hepatic encephalopathy was also treated. The outcome was favourable (extubation, resolution of febrile syndrome, inflammation, jaundice and hepatic encephalopathy).

This case is an example of atypical, monophasic leptospirosis which is common in Weil's disease (the most severe form of leptospirosis), with onset as a febrile illness leading to multiple system organ failure.

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Drug Hepatitis At AINS

Abstract

Hepatic lesions induced by drugs include extremely diverse various clinical, biological and histological manifestations that can determine acute or chronic hepatobiliary disease. The term of hepatitis is recommended to be used when there is a histological confirmation. In the last decades a 11 time increase of the hepatic lesions induced by drugs is reported, due both to the increase of the number of used drugs but also by their more frequent recognition.

We carried out a combined retrospective study and longitudinally prospective study that included patients with drug hepatitis. In our study there were 83 cases of drug hepatitis at AINS, which represents 33.46 % of the total number of 248 patients with drug hepatitis. In our study the highest drug hepatitis at AINS were Nimesulid (24 cases), followed by Diclofenac (21 cases), and the fewest at Piroxicam (9 cases). All the cases from the study were symptomatic, showing the increase of the cytolysis enzymes and sometimes cholestasis enzymes (mainly GGT).

The average age at diagnosis was 60.1 years for the 248 patients, being lower for the male gender (57.47 years), compared to the female gender (61.26 years). Women were affected in the highest degree, 69.35% being women and 30.64% men. In our study drug hepatitis by hepatic cytolysis was dominant, more frequent than the cholestatic ones.

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Favorable outcome in a patient with systemic BCGitis after intra-bladder instillation of Calmette-Guerin Bacillus highlighting the importance of making the correct diagnosis in this rare form of sepsis

to the intensive care unit (ICU) and amoxicillin-clavulanic acid was initiated. Blood testing highlighted an inflammatory syndrome [C-reactive protein (CRP) between 70 and 90 mg/L, < 10] and hepatic cytolysis and cholestasis evoking liver involvement. Sediment and urinary cultures were negative. Blood cultures for mycobacteria were done after nightly fever peaks. Empirical anti-tuberculous treatment was started associating isoniazid, rifampicin and vitamin B6 in the event of a BCGitis. Chest X-Ray ( Figure 1 ) showed an interstitial syndrome. Figure 1 Chest X

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