noon report

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.

Terminal Ileitis!

Dr. Tyler Wells presented a great case at noon report making us all scratch our heads and realize the importance of recognizing anchoring bias.

A 26 year old man presented with 4 weeks of RLQ pain, nonbloody diarrhea, fever and weight loss. He had no history of immunosuppression or clear exposures. He had a CT scan showing mass-like wall thickening of the terminal ileum concerning for cancer. This lead to to an extensive work up including a colonoscopy with biopsy showing inflammation but no malignancy. He had a repeat CT weeks later which showed complete resolution of inflammation. His diarrhea had also resolved. In reviewing the history, his course fit best with Yersinia ileitis (though he never had stool studies to confirm).

This led to a vibrant discussion about the differential for terminal ileitis. Our beloved Program Director, Sima, provided us with her short differential for ileitis. Also see this article (Facing Terminal Ileitis: Going Beyond Crohn's Disease) for a more extensive discussion on the differential.

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