efim winter school of internal medicine case...
TRANSCRIPT
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EFIM Winter School of Internal MedicineCase Presentation
Johan Van Laethem, January 2015
(Belgium)
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Interesting numbers
3
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Official languages
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3
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8 0
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Interesting statistics% of billiart players use Belgian (made) balls
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2,3
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Tallest European man: Alain Delaunois
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1
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Using discount coupons (2nd USA)
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540
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540 days without government in 2011
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22
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22 kg of chocolate ingested/y
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68
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68 y: life expectancy anaesthesiologist
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92 y: life expectancy radiologist
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1. Introduction
Systemic interrogation:
- Referral GP: cytolysis, cholestasis since 1 month, asthenia
- Fatigue, muscle waisting
- No history of alcohol intake
Physical examination:
- Lean
- Icterus
- Asterixis after few days
- Parameters stable
Medication intake:
-Iron supplementation
-Tamsulosin (alfa-blocker)
-Aspirin 80 mg/d
-Protein powder (Nutricia)
Medical history:
-Partial gastrectomy 1983, gastric carcinoma
-2012 intestinal operation
-Benign prostate hypertrophy
-Iron deficiency
Male, 68 yr
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2. Diagnostic work-up: lab results and imaging
ANCA’s, ANF, LKM Ab, smooth muscle Ab, anti-mitochondrial Ab: negativeAbdominal CT en echography: normal liver morphology, no biliary stones nor bile duct dilatation
01/1207/1212/12
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3. What would you do?
A. Treat the patient with corticosteroidsB. Perform a liver biopsyC. Watchful waitingD.Refine the interrogationE. Put the patient on the liver transplantation list
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4. Refined interrogation and clinical evolution
12/12:
Hepatic encephalopathy
01/12:
Rise of liver tests
Patient still responsive
24/11:
Cytolysis, bili 1,5 g/dl
09/10:
Start protein powder
3/10:
Normal Liver tests
Refined interrogation and clinical evolution
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Low ceruloplasmin
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Wilson’s disease?
Low ceruloplasmin (PPV 6%):• Wilson’s• Acute viral hepatitis • Chronic hepatitis • Drug-induced liver injury (DILI)• Alcohol-induced liver disease• Malabsorption
Split lamp examination: no Kaiser Fleischer rings (sensitivity 60%)
Nonceruloplasmin-bound copper (mcg/L) = serum copper (mcg/L) – (3.15 mcg/g x serum ceruloplasmin [mg/L])Wilson’s: free copper typically > 20-25 mcg/dl
HES staining and picture: prof. A. Hoorens
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6. Management: what would you do?
A. Discontinuation of the medicationB. Discontinuation of the protein powderC. Start corticosteroidsD. Lactulose for hepatic encephalopathyE. Something else?
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7. Cause of the medicamentous/ toxic hepatitis?
1. Iron supplementation/ Aspirin/ Tamsulosin ??
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8. Protein powder?
“Thank you for the information…but it seems unlikely the liver failure was due to our product because the patient ingested 4,4-8,8 g of proteins a day, which would be equal to the protein amount of 1 glass of milk.”
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Clinical and biochemical evolution
• Slow decrease cytolysis and bilirubin over time, correction of PT• Decrease of icterus• Patient still weak • PET-CT: no particularities
Based on the chronology of liver failure our first hypothesis is liver failure due to protein powder
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Unanswered questions
Place of corticoids?(no proof of beneficial effects, only hypersensitivity reactions)
Causative drug/ supplement?
Cause of progressive hypoalbuminemia?
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Conclusions
1. Drug induced liver injury (DILI) is frequent (15-30% acute liver failures)2. Liver biopsy is useful in diagnosis3. Identification of causative drug is difficult, no routine test. Re-challenge is
difficult.4. Cornerstones of treatment: discontinuation of the drug, sometimes liver
transplant5. Corticotherapy has no proven effect but can be tried in evident
hypersensitivity
Thank you for listening
Thank you for listening
Thank you for listening
Thank you for listening