Alexander M. Sy

Hispanic ethnicity is associated with increased morbidity and mortality in patients with alcoholic liver disease

Alcoholic liver disease (ALD) encompasses a broad spectrum of liver pathology, from steatosis to alcoholic steatohepatitis, cirrhosis, and hepatocellular carcinoma. Alcohol has a synergistic effect with other chronic liver diseases leading to accelerated progression. Racial and ethnic differences have been documented for some chronic diseases, including hypertension, heart failure, and ALD. Women are more susceptible to ALD than men when exposed to similar amounts of alcohol, and Hispanics are more prone to develop ALD than blacks and Caucasians.1,2 Accordingly, the aim of this study was to characterize patients with ALD admitted to a community hospital that serves a predominantly Hispanic population in East Harlem in New York City to learn the spectrum of liver disease in hospitalized patients from the community. We conducted a retrospective review of charts of patients aged 18 to 85 years admitted to the Medicine service at Metropolitan Hospital Center with a diagnosis of ALD identified by the use of ICD-9 codes from 2002, when the hospital instituted its electronic medical records, to 2011. Demographic data, co-morbidities, intensive care unit admission, and need for mechanical ventilation were recorded. The 3 months survival after discharge was also documented. Pregnancy, incomplete documentation, and anticoagulation therapy were the exclusion criteria. Statistical analysis was done by the use of χ2 and Fisher exact test for categorical data by the use of SAS program. A p value of < 0.05 was considered statistically significant. The study was approved by the New York Medical College Institutional Review Board. ALD was identified in 165 patients. The group was comprised of 138 males and 27 females, 118 of whom (71.5%) were of Hispanic and 47 (28.5%) were of non-Hispanic ethnicity, which was comprised of 34 blacks, 12 Caucasians and 1 Asian. The average age was 53 years. The comorbidities and alcohol use in the study group is provided in the table. The proportion of patients that reported drinking at the time of admission and the estimated daily grams of alcohol consumed by the subjects was higher in the non-Hispanic group than in the Hispanic group, both exhibiting a statistically significant difference; however, data on these two factors were not available in all patients (Table 1). There was a significant difference between the number of non-Hispanic (n = 104) and Hispanic (n = 7) patients who did not require intensive care unit admission (p = 0.015). There was also a significant difference between non-Hispanic (n = 16) and Hispanic (n = 7) patients who did not require mechanical ventilation. In addition, a significant association was found for patients who did not require mechanical ventilation stratified by non-Hispanic (n = 132) population and Hispanic women (n = 10) (p = 0.0006) although, the need for mechanical ventilation was not different between Non-Hispanic (n = 9) and Hispanic women (n = 10) (p = 0.086). Eighteen of the 165 patients had died at 90 days post admission, 12 nonHispanic and 6 Hispanic. In a stratified analysis, there was a significant association between mortality and the Hispanic women group and non-Hispanic patients (p = 0.0007); however, the 90 day mortality for Hispanic (n = 6) vs. non-Hispanic women (n = 1) was not significantly different (p = 0.20). The study revealed that the majority of patients admitted to the hospital with ALD was of the Hispanic ethnicity. This finding may be a reflection of the population that uses the hospital for care; however, it raises the question of a potential increase in the prevalence of ALD in the Hispanic group. An important finding of this study was that ALD was associated with heightened morbidity and mortality, as The Official Journal of the Mexican Association of Hepatology, the Latin-American Association for Study of the Liver and the Canadian Association for the Study of the Liver

Pulmonary aspergillosis presenting with recurrent haemoptysis

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.

Large interventricular septal aneurysm with thrombo-embolism in a healthy woman

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 …

Hepatic Cyst Compressing The Right Atrial and Ventricular Inflow Tract: An Uncommon Cardiac Complication

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.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.

Multifocal Osteoarticular Tuberculosis in a Lupus With Sjogren Syndrome Patient.

intranasal ketamine in children for pain relief.4 However, to the best of our knowledge, our case is the first to use intranasal ketamine to reduce pain for a 2year-old child. Ketamine provides its effects by blocking the N-methyl-D-aspartate receptor.2 For safety, patients should be monitored for dizziness or dysphoria.5 In patients who are not candidates to receive intravenous or intramuscular medications, intranasal SDDK may be viable alternative for pain relief.

Combination of Triple Therapy and Chronic PPI Use May Decrease Risk of Colonic Adenomatous Polyps in Helicobacter pylori Infection

Aim. The aim of the paper is to determine association between H. pylori and colonic adenomatous polyps and to explore whether treatment or chronic PPI use can mitigate this risk. Methods. This case-control study included 943 patients who had H. pylori testing and underwent colonoscopy. Presence of polyps was the outcome of interest, whereas age, sex, race, H. pylori infection, triple therapy, and chronic PPI use were independent variables. Multivariate regression analysis was used to calculate odds ratios at 95% confidence intervals. This study was approved by the New York Medical College Institutional Review Board. Results. H. pylori was associated with increased odds of colonic adenomatous polyps (adjusted OR 1.43, 95% CI 1.04–1.77), with stronger association among patients older than 50 (OR 1.65, 95% CI 1.18–2.33). Triple therapy (OR 0.69, 95% CI 0.44–1.07) or chronic PPI use (OR 0.69, 95% CI 0.43–1.09) decreased odds of polyp formation. Analysis revealed a statistically significant reduction in patients who received both triple therapy and chronic PPI, lowering the odds by 60% (adjusted OR 0.43, 95% CI 0.27–0.67). Conclusion. There is increased risk of colonic adenomatous polyps among H. pylori-infected patients. Triple therapy or chronic PPI use may mitigate this risk, with further reduction when these two interventions are combined.

Utility of pleural fluid n-terminal pro-brain-type natriuretic peptide in recurrent unilateral pleural effusion due to congestive heart failure

Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Lancellotti: literature review, data collection. Lancellotti, Cohen-Bittan, Boddaert: manuscript preparation. All authors: critical review and approval. Sponsor’s Role: None.

Hepatocellular carcinoma in a patient with chronic lymphocytic leukaemia involving the liver.

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.

Salmonella enterica Serotype Choleraesuis Infection of the Knee and Femur in a Nonbacteremic Diabetic Patient

Osteoarticular infections caused by Salmonella are rare. The rates of osteomyelitis and septic arthritis due to Salmonella are estimated to be less than 1% and 0.1%-0.2%, respectively (Kato et al., 2012). Salmonella enterica serotype Choleraesuis is a nontyphoidal 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 of Salmonella infections 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 with Salmonella enterica serotype Cholerasuis, but without evidence of bacteremia.

Acute cytomegalovirus hepatitis in an immunocompetent host

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.