Anuj Datta

Troxis necrosis, a novel mechanism for drug-induced hepatitis secondary to immunomodulatory therapy.

OBJECTIVES A case of drug-induced hepatitis mediated by troxis necrosis, a form of autoimmune hepatitis, is described. METHODS Clinical data, light and electron microscopy of an ultrasound-guided core needle liver biopsy specimen, were examined to investigate the cause of transaminitis in a 26year old male patient on Cellcept and Plaquenil for the treatment of lupus erythematosus. A systematic PUBMED review of troxis necrosis as the underlying mechanism for drug-induced hepatitis was performed. RESULTS Liver function tests (LFTs) were significant for elevated AST (305) and ALT (174); the autoimmune workup was significant for anti-ANA positivity and α-SMA negativity. On light microscopy, the liver biopsy shows focal areas of lymphocytic infiltrates surrounding and forming immunologic synapses with lobular hepatocytes, indicating lobular hepatitis of autoimmune nature. Electron microscopy confirmed the presence of immunologic synapses. Upon cessation of the offending medications, the LFTs returned to baseline with no further intervention. Literature search yielded 7 previously reported cases of drug-induced hepatitis mediated by troxis necrosis. CONCLUSION Troxis necrosis is a novel mechanism for drug-induced hepatitis, including immunomodulatory medications including a monoclonal anti-TWEAK antibody and Cellcept and Plaquenil, two widely used immunosuppression/anti-rejection medications.

Endoscopic retrograde cholangiopancreatography with intraductal ultrasound in pregnancy without the use of radiation

Goals and background: Biliary disease in pregnancy presents unique challenges. Conservative treatment is associated with recurrent symptoms, and the use of radiographic imaging is limited because of the possibility of fetal exposure. The aim of our study was to evaluate the use of intraductal ultrasound (IDUS) in nonradiation ERCP (ERCP-NR) to treat pregnant women with symptomatic choledocholithiasis or gallstone pancreatitis. Study: From 2008 to 2014, we retrospectively identified ten pregnant patients at our urban safety net teaching hospital who were treated with IDUS-guided ERCP for symptomatic choledocholithiasis or gallstone pancreatitis. The cases were compiled to provide a descriptive review of ERCP with IDUS. Results: Of 10 pregnant patients who underwent ERCP, eight patients had prior EUS demonstrating common bile duct stones, and two had gallstone pancreatitis. There were no immediate procedure-related adverse events and no patients required a repeat procedure. All ERCP procedures were successful for removing the bile duct stones and providing symptomatic relief. There were no known immediate or long-term procedure-related adverse events in the infants. Conclusions: IDUS-guided ERCP-NR provides appropriate biliary imaging without fetal radiation exposure and can be safely and successfully performed in pregnancy. Correspondence to: Dr. Anuj Datta, Division of Gastroenterology/Hepatology, Harbor-UCLA Medical Center, Torrance, CA 90502, USA, Tel: (310) 222-2475; E-mail: adatta@dhs.lacounty.gov