infectious disease

Liver Abscess

Dr. Johnny Cai presented a case of a woman with a history of a pancreatic tail cyst who had two weeks of progressive RUQ pain, fever, and night sweats. She was hemodynamically stable, but her labs revealed a hepatocellular liver injury and a severe leukocytosis. RUQ ultrasound revealed pneumobilia without common bile duct dilatation, cholelithiasis or pericholecystic fluid.

Pneumobilia, you say?

The differential for pneumobilia is short -- post-procedural vs BADNESS (like gas-producing bacterial infection).

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The team then proceeded with a CT (shown here):

“gas and fluid filled structure 5x4 cm in segment 4 of the liver consistent with abscess without clear source.”

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When thinking about a liver abscess, it can be helpful to try to classify it further into pyogenic (most common) vs less common causes such as amebic or unusual infections (TB, Echinococcus, candidal). Your history should alert you if you should be thinking about atypical liver abscesses. Echinococcus has a very distinct look on imaging and should not be aspirated for culture as this can be lethal.

You should also ensure you get blood cultures as liver abscesses can form from hematogenous spread.

A liver abscess?

The patient was started on pipercillin/tazobactam and IR aspirated the liver abscess and placed a drain. The aspirate culture never grew anything (suspected sterilized with antibiotics).

Her leukocytosis was not improving and thus she was -reimaged without change in abscess and had another drain placed. THIS IS A GOOD TEACHING POINT: if the clinical picture isn’t improving, make sure you truly have source control (drain not in right place, another process going on, wrong antibiotics, etc.) After her clinical picture started to improve, she was transitioned to metronidazole and moxifloxacin to complete a 6 week course.

References:

  • UptoDate “Pyogenic Liver Abscess”

  • Lübbert C, Wiegand J, Karlas T. Therapy of Liver Abscesses. Viszeralmedizin. 2014;30(5):334–341

  • Rathimian, J et al. Clinical Infectious Diseases. 2004 Dec 1;39(11):1654-9

  • Tan YM, Chung AY, Chow PK, et al. Ann Surg. 2005;241(3):485–490

  • Wong, Wai Man et al. Journal of Gastroenterology and Hepatology. (2002) 17, 1001–1007

HIV for the Internist!

Dr. Spencer mixed up Noon Report today and educated the VA residents about HIV, anti-retrovirals, and special health care maintenance needed for patients with HIV.

Screening for HIV is indicated at least once for all patients between ages 13 -65 (CDC and USPTF) and after any high risk behavior or exposure. For HIV screening, we start with the 4th generation Ag/Ab Immunoassay which becomes positive much more quickly than the traditional western blot.

 

Don’t forget that Antigen/Antibody positivity takes~17 days. If high clinical suspicion for acute HIV, get a HIV viral load/PCR.

If a patient comes in with a positive home POC test you should still start the algorithm at the beginning with Ag/Ab immunoassay.

 
 
 

 
 

NRTIs:

Tenofovir: side effects include renal dysfunction, osteoporosis

Abacavir: requires HLAB5701 testing due to risk of hypersensitivity reaction

Emtricitabine: side effects include dyslipidemia

NNRTIs:

induces CYP 2A which can interact with Keppra

Efavirenz: neuropsychiatric side effects

Rilpivirine: cannot be started when VL >100K; cannot use with PPI (requires acid for absorption)

Protease Inhibitors and Boosters (ritonavir, darunavir, atazanavir)

CYP inhibition:

  • can increase statin levels and cause myopathy and rhabdomyolysis

  • inihibit steroid metabolism which can cause iatrogenic Cushing’s

  • side effects include dyslipidemia

Integrase inhibitors (raltegravir, dolutegravir)

  • New data questioning potential for neural tube defects during pregnancy

  • Interacts with divalent cations (cannot take with Mg, Ca supplements)

Entry Inhibitors:

Maraviroc: requires tropism testing

Thanks Dr. Spencer!


References:

•Deeks SG, Lewin SR, Havlir DV. The end of AIDS: HIV infection as a chronic disease. Lancet. 2013;382(9903):1525–1533. doi:10.1016/S0140-6736(13)61809-7

•Branson BM et.al Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. 2006. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm

 
 

Acute Liver Failure and Hyperferritinemia!

Dr. Gardner presented a great case of a man who was recently started on steroids that developed diffuse weakness and vesicular facial rash. His labs revealed acute liver failure (hepatocellular pattern with AST and ALT in 10,000s), thrombocytopenia, and a ferritin of 15,000! Our residents discussed the differential for transaminases greater than 1000, and our graduating resident, Dr. Jared Huber, gave an excellent mneumonic of "VITAMIN-C" to help us rememeber.

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We also were reminded of causes of elevated ferritin, including disseminated fungal and viral infections. Because of the severity of this man's presentation, numerous medical teams were consulted. The diagnosis of HLH was entertained, but the patient did not meet criteria, and BM biopsy was negative. Ultimately, he was found to had disseminated HSV (confirmed with skin biopsy) causing his acute liver failure and hyperferritinemia. This case is a great reminder that when you are in a diagnostic dilemma, it can be helpful to go back to the presentation (his vesicular facial rash) and you may just find the diagnosis.