Isolated hepatic actinomycosis: a case report.

INTRODUCTION: Actinomyces are slow growing, non-spore forming, gram-positive, branching bacilli that thrive in anaerobic and microareophilic conditions. Actinomyces are more commonly associated with oral and cervicofacial infections. Hepatic involvement in infections of the abdomen (known as isolated hepatic actinomycosis) is rare, accounting for only 5% of all cases of actinomycosis. CASE PRESENTATION: We present the case of a 75-year-old Caucasian woman with a 3-month history of night sweats, fever, chills, abdominal bloating, anorexia, weight-loss, and early satiety. The patient was found to have isolated hepatic actinomycosis infection after undergoing a laparotomy with a biopsy of the liver. The patient has now recovered. CONCLUSION: Isolated hepatic actinomycosis is a rare and often overlooked etiology for a liver mass. Given its subacute presentation and nondescript symptomatology, physicians should be aware of this differential and the potential pitfalls in diagnosis and management.

Giant ileal inflammatory fibroid polyp causing small bowel obstruction: a case report and review of the literature.

INTRODUCTION: There are several types of small bowel pathology that can lead to small bowel obstruction or intussusception. The etiology causing small bowel obstruction varies by age. Benign disease is the typical cause in children and adolescents while malignant or adhesive disease is far more common in older patients. Although cases of adult intussusception caused by benign processes are rare, there are reports of inflammatory fibroid polyps causing adult intussusception of the terminal ileum published in the literature. CASE PRESENTATION: We present the case of a 70-year-old man with a multiple year history of intermittent episodes of bowel obstruction who was found to have a giant ileal inflammatory fibroid polyp causing intermittent small bowel obstruction. The patient underwent operative intervention and has now been symptom-free for three years. CONCLUSION: Small bowel lesions include both malignant and benign etiologies. The malignant etiologies include adenocarcinoma, carcinoid or lymphoma while benign lesions are typically lipomas, inflammatory polyps or adenomas. Inflammatory fibroid polyps are rare, benign lesions that can occur anywhere within the gastrointestinal tract. They are typically an incidental finding, but on rare occasions have been presented as the source of intussusception or obstruction.

Rapidly progressive metastatic multicentric epithelioid angiosarcoma of the small bowel: a case report and a review of literature.

BACKGROUND: Angiosarcoma is a rare high-grade neoplasm that frequently involves the skin and subcutaneous tissue. Rarely, angiosarcoma can occur in the gastrointestinal tract where it frequently exhibits multicentric epithelioid morphology. DESIGN: We report a case of multicentric epithelioid angiosarcoma (EAS) of the small intestine in a 73-year-old male patient who presented with weakness and melena, and was found to have bleeding lesions in the small intestine on upper gastrointestinal endoscopy. In addition to this case, we extensively reviewed the clinical and pathological features of previously reported cases of angiosarcoma of the small intestine in the English literature since 1970. RESULTS: Our patient presented with rare and aggressive EAS of the small intestine. Despite surgical resection of the lesions, the patient continued to worsen and developed rapidly progressive metastatic disease. He died within 4 months of the diagnosis. CONCLUSIONS: Angiosarcoma, especially of the deep tissues and the gastrointestinal tract, is very aggressive and rapidly metastatic. The survival rate in these patients is extremely poor, and most patients die within 6 months to 1 year of the diagnosis. Treatment usually involves surgical resection of the bleeding lesions and frequent blood transfusions for symptom alleviation.

A fatal case of bupropion (Zyban) hepatotoxicity with autoimmune features: Case report.

BACKGROUND: Bupropion is approved for the treatment of mood disorders and as an adjuvant medication for smoking cessation. Bupropion is generally well tolerated and considered safe. Two randomized controlled trials of bupropion therapy for smoking cessation did not report any hepatic adverse events. However, there are three reports of severe but non-fatal bupropion hepatotoxicity published in the literature. CASE PRESENTATION: We present the case of a 55-year old man who presented with jaundice and severe hepatic injury approximately 6 months after starting bupropion for smoking cessation. Laboratory evaluation demonstrated a mixed picture of hepatocellular injury and cholestasis. Liver biopsy demonstrated findings consistent with severe hepatotoxic injury due to drug induced liver injury. Laboratory testing was also notable for positive autoimmune markers. The patient initially had clinical improvement with steroid therapy but eventually died of infectious complications. CONCLUSION: This report represents the first fatal report of bupropion related hepatotoxicity and the second case of bupropion related liver injury demonstrating autoimmune features. The common use of this medication for multiple indications makes it important for physicians to consider this medication as an etiologic agent in patients with otherwise unexplained hepatocellular jaundice.

Knowledge of hepatitis C screening and management by internal medicine residents: trends over 2 years.

OBJECTIVES: Over 2 million people in the United States are infected with hepatitis C, and there has been an explosion in knowledge regarding this disease in the last decade. Internal medicine residents must be able to identify patients at risk for hepatitis C and institute appropriate diagnostic testing and referral of these patients. METHODS: A survey regarding hepatitis C risk factors and the management of hepatitis C patients was administered on three occasions over 15 months (time 0, 1 month, and 15 months) to members of a large university-based internal medicine residency. RESULTS: During the study period 59 residents completed all three surveys. Less than half of the residents (39%) ask patients about hepatitis C risk factors. Only 58% reported that they would refer a hepatitis C antibody positive patient with elevated liver enzymes to a subspecialist on the initial survey. The residents who did not refer patients cited low response rates, high side-effect profiles, and the high cost of therapy as reasons for not referring the patient. There was significant improvement (58% vs 78%, p < 0.01) in the rate of patient referral during the 15-month study period but no substantial improvement in the other knowledge deficits. CONCLUSIONS: The knowledge base of the internal medicine residents about hepatitis C screening and management is suboptimal. New, more effective hepatitis C education programs for internal medicine residents should be initiated.

Identification and management of hepatitis C patients in primary care clinics.

OBJECTIVE: Previous survey-based research suggested that hepatitis C patients receive suboptimal care in primary care settings. The aim of our study was to define the actual level of care hepatitis C patients receive in primary care clinics. METHODS: Medical records of 229 hepatitis C antibody-positive (group 1), 229 hepatitis C antibody-negative (group 2), and 229 patients not tested for hepatitis C antibody (group 3) were reviewed to assess the indications for hepatitis C testing and the subsequent management and referral of hepatitis C antibody-positive patients diagnosed in primary care clinics. In addition, the compliance of primary care physicians with hepatitis C screening and testing guidelines was assessed. RESULTS: Only 16% of group 1 and 10% of group 2 patients were tested for hepatitis C based on physician-identified risk factors. Only 1% of group 3 patients had documented discussion of hepatitis C risk factors during their initial visit with a primary care physician. The majority of hepatitis C antibody-positive patients was appropriately evaluated in primary care clinics, and most (77%) hepatitis C RNA-positive patients with elevated liver enzymes were referred for subspecialty care. Of the 59 patients who underwent liver biopsy, 40% had bridging fibrosis or cirrhosis. CONCLUSIONS: Hepatitis C testing is rarely initiated in primary care clinics based on physician-identified risk factors. Interventions should be developed to optimize early diagnosis of hepatitis C as significant liver disease may be present despite the absence of symptoms.

Effectiveness of interferon alpha-2b and ribavirin combination therapy in the treatment of naive chronic hepatitis C patients in clinical practice.

BACKGROUND & AIMS: Studies in many diseases have shown that efficacy in clinical trials often does not translate into effectiveness in clinical practice. The aims of this study were to determine the rate of sustained virological response (SVR) and the factors associated with SVR in therapy naive chronic hepatitis C patients treated with interferon alpha-2b and ribavirin combination therapy at a university outpatient clinic. METHODS: The medical records of 153 consecutive chronic hepatitis C patients treated between June 1998 and May 2001 were reviewed. RESULTS: The mean subject age was 44 years, 64% were men, 85% were white, 56% had HCV genotype 1, and 21% had cirrhosis on biopsy. The overall SVR rate was 42% (29% in genotype 1/4; 65% in genotype 2/3). Side effects resulted in interferon or ribavirin dose reductions in 22% of patients and premature termination of treatment in 10%. The SVR rate was significantly higher in the 102 patients who received >80% of the recommended dose and duration of therapy compared with the 51 patients who did not (53% vs. 20%, P = 0.00008). HCV genotype, subject race, and adherence were independently associated with SVR (P < 0.01). Although the incidence of side effects and medication adherence was similar in blacks and whites, adherent blacks had a significantly lower SVR rate (14% vs. 58%, P < 0.01). CONCLUSIONS: Despite the inclusion of a broader spectrum of patients and less frequent monitoring, combination antiviral therapy in our treatment-naive chronic hepatitis C patients was of similar efficacy to that reported in large multicenter trials. In addition, our data show that medication adherence is an important predictor of SVR in an academic clinical practice.