Primary Biliary Cholangitis With Pulmonary Manifestations and Concurrent Enterococcus Pneumonia: A Diagnostic Challenge Resembling Sarcoidosis or Silicosis.

Primary biliary cholangitis (PBC) is common in females during middle age, presenting with fatigue and itching. In our case, an African-American male patient presented with abdominal pain, vomiting, fatigue, and lung manifestations such as interstitial lung disease, granulomatous lung disease, and pulmonary hypertension. In our case, the patient reported abdominal pain and fatigue with abnormal chest X-ray findings (bilateral pulmonic nodular lesion with calcifications), which mimicked silicosis/sarcoidosis lung findings such as bronchiectasis and parenchymal nodules. We diagnosed PBC as there was an absence of extrahepatic biliary obstruction and the presence of antimitochondrial antibodies (AMA) at a titer of 1:40 or higher. Bronchoalveolar lavage was performed due to the suspicion of interstitial lung disease and sarcoidosis, which was inconclusive but revealed enterococcus faecalis organisms. Initial antibiotic response heightens suspicion of infection, not colonization, leading to the diagnosis of enterococcal pneumonia. In our case, the diagnosis was made using clinical and laboratory criteria, and treatment with Ursodeoxycholic acid was opted for without resorting to more expensive and invasive tests like magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP). In summary, this case report presented the unique diagnostic challenges that will aid clinicians in considering a broad range of differential diagnoses and management plans.

Ginseng-Related Drug-Induced Liver Injury.

Ginseng is commonly used as a medicinal herb for memory and concentration and general well-being. Drug-induced liver injury (DILI) is one of the most challenging disorders and trending events in the United States which are related to body building and weight loss supplements. Currently, herbal and dietary supplementation is the second most common cause of DILI. Here, we report on a 45-year-old healthy Chinese woman who presented with dull intermittent left upper quadrant abdomen pain for a month. Upon thorough history taking, she had been taking ginseng tea and supplementation for her menopausal symptoms for almost 3 months. Physical examination was unremarkable except mild tenderness in left upper quadrant of the abdomen. Liver function test showed aspartate transaminase (AST) 717 U/L, alanine transaminase (ALT) 343 U/L, total bilirubin 5 mg/dL, direct bilirubin 3.3 mg/dL, alkaline phosphatase 182 U/L, with international normalized ratio (INR) 1.2. Prior liver enzymes (6 months earlier) showed AST 21 U/L, ALT 18 U/L, total bilirubin 0.8 mg/dL, direct bilirubin 0.3 mg/dL, alkaline phosphatase 34 U/L, with INR 0.7. Viral serology for acute hepatitis B, C, E, cytomegalovirus, Epstein-Barr virus, and varicella zoster virus was negative. She was immune to hepatitis A. Her antinuclear antibody was positive. Her anti-Smith antibody, anti-smooth muscle antibody, HFE gene mutation, ceruloplasmin, alpha-1 antitrypsin serologies were within normal references. An abdomen sonogram showed fatty infiltration. Liver biopsy showed moderate to severe portal inflammation and marked lobular disarray. Portal and lobular inflammatory infiltrates consisted of a mixture of histiocytes, lymphocytes, plasma cells, eosinophils, and neutrophils with centrilobular necrosis and focal bridging necrosis, and necro-inflammation. After 6 weeks of follow-up, the patient improved physically, and the abdomen pain resolved. Ginseng has been widely used in the Chinese community as medicinal herb for a variety of conditions for decades. However, proper research has never been done regarding its pharmacokinetics, efficacy, and safety issues. In our case report, the idiosyncratic DILI resulted from ingestion of ginseng as herbal supplementation for premenopausal symptoms. Physicians should be aware of and suspect DILI in any patient with acute liver injury, and patients should be reminded that all medications and supplements have a potential to cause DILI.

An Unusual Presentation of Acute Abdomen Pain: Splenic and Renal Emboli from Left Ventricular Thrombus.

Splenic infarction is an unusual cause for a patient to present with left upper abdomen pain. A 47-year-old woman presented to the emergency department with left upper abdomen pain. She reported that she stopped taking warfarin two days prior to presentation. A physical examination revealed fine crackles within the left lower lobe and significant tenderness within the left upper abdomen. Computed tomography of the abdomen showed mild cardiomegaly with a 2.3 cm calcified thrombus in the left ventricular apex. We noted infarction in the spleen and right kidney with bilateral renal scarring. The patient was initially started on a heparin drip and later bridged to warfarin on the third day. She was discharged after seven days with complete resolution of the abdominal pain. The decision to prescribe an anticoagulant should include a consideration of underlying causes, comorbidities, an assessment of risks and benefits, and chances of recurrence. In our patient, her new splenic infarct and renal infarction were most likely embolic in origin due to her left ventricular apical aneurysm with thrombus and nonadherence to her prescribed anticoagulation medication.