Bifocal malakoplakia in a patient living with HIV: case report.

BACKGROUND: Malakoplakia is a rare chronic granulomatous disease characterized by the presence of Michaelis-Gutmann bodies (MGBs) within histiocytic aggregates. It predominantly affects immunocompromised individuals, including those living with Human Immunodeficiency Virus (HIV). CASE PRESENTATION: We present a unique case of bifocal malakoplakia in a 49-year-old man, previously with Coronavirus disease 2019 (COVID-19) and HIV positive, presented with respiratory symptoms, weight loss, and lymphadenopathy. He had various infections including Non-Tuberculous Mycobacteria (NTM), Cytomegalovirus (CMV), and Candida, with evolving lung and gastrointestinal issues. Despite treatment attempts, he deteriorated due to respiratory distress, multi-organ failure, and coagulopathy, leading to his unfortunate demise. CONCLUSION: This report presents a distinctive and complex case of malakoplakia in an HIV-positive patient, a rare inflammatory disorder originally described by Michaelis and Gutmann in 1902. The hallmark Michaelis-Gutmann organisms were observed, confirming the diagnosis. While typically affecting the urinary tract, this case demonstrates the exceptional ability of malakoplakia to manifest in various organ systems, including pulmonary, gastrointestinal, and more. Although Escherichia coli is a prevalent associated pathogen, the exact cause remains elusive. Treatment, often involving surgical excision and antibiotic therapy, underscores the challenging nature of managing this condition in immunocompromised individuals.

Spontaneous Clearance After Relapse Following Direct-Acting Antiviral Treatment for Chronic HCV Infection.

BACKGROUND & AIMS: Direct-acting antivirals (DAAs) cure most cases of chronic hepatitis C virus (HCV) infection. However, a small percentage of patients relapse with reappearance of viremia after a full course of therapy. Although most who relapse require retreatment, some patients spontaneously clear HCV without additional therapy. We studied patients who relapsed with detectable HCV RNA after a full course of DAA therapy and then spontaneously cleared the HCV infection without retreatment. METHODS: We performed a case-control study of patients who spontaneously cleared chronic HCV infection following a documented relapse after DAA therapy at the Toronto Centre for Liver Disease, from January 2014 through December 2017. We collected clinical information at baseline, 12 weeks after treatment, and 6 months after relapse and compared data among spontaneous clearers, patients with persistent relapse, and patients who achieved a sustained virologic response to therapy 12 weeks after treatment (SVR12). The strength and breadth of interferon gamma cytokine secretion by HCV-specific T cells from peripheral blood were quantified using the ELISPOT assay. RESULTS: Of the 1032 individuals with chronic HCV infection who were treated with DAAs, 93 patients had a documented relapse. Of these patients, 12 patients (13%) spontaneously cleared HCV within 6 months after the documented relapse without additional therapy. The spontaneous clearers had low levels of HCV RNA (<4 log IU/mL in 11 of 12) and normal levels of alanine aminotransferase at the time of relapse, much like patients with an SVR12. There was no significant difference between the spontaneous clearance group and the SVR12 group in magnitude and breadth of HCV-specific T cell responses. CONCLUSIONS: In a case-control study of patients who spontaneously cleared chronic HCV infection following a relapse after DAA therapy, we found that it is important to confirm viremia prior to retreatment after the relapse-particularly for individuals with low levels of HCV RNA and normal or near-normal levels of alanine aminotransferase after treatment.

Denosumab-induced autoimmune hepatitis: Case report.

This report described a patient not known to have a hepatic disease, found to have a drug-induced autoimmune hepatitis from denosumab. This is an unreported side effect, and here, we presented the possible predisposing factors and suggested monitoring parameters.

Development and validation of an ensemble machine learning framework for detection of all-cause advanced hepatic fibrosis: a retrospective cohort study.

BACKGROUND: Cirrhosis is the result of advanced scarring (or fibrosis) of the liver, and is often diagnosed once decompensation with associated complications has occurred. Current non-invasive tests to detect advanced liver fibrosis have limited performance, with many indeterminate classifications. We aimed to identify patients with advanced liver fibrosis of all-causes using machine learning algorithms (MLAs). METHODS: In this retrospective study of routinely collected laboratory, clinical, and demographic data, we trained six MLAs (support vector machine, random forest classifier, gradient boosting classifier, logistic regression, artificial neural network, and an ensemble of all these algorithms) to detect advanced fibrosis using 1703 liver biopsies from patients seen at the Toronto Liver Clinic (TLC) between Jan 1, 2000, and Dec 20, 2014. Performance was validated using five datasets derived from patient data provided by the TLC (n=104 patients with a biopsy sample taken between March 24, 2014, and Dec 31, 2017) and McGill University Health Centre (MUHC; n=404). Patients with decompensated cirrhosis were excluded. Performance was benchmarked against aspartate aminotransferase-to-platelet ratio index (APRI), fibrosis-4 index (FIB-4), non-alcoholic fatty liver disease fibrosis score (NFS), transient elastography, and an independent panel of five hepatology experts (MB, GS, HK, KP, and RSK). MLA performance was evaluated using the area under the receiver operating characteristic curve (AUROC) and the percentage of determinate classifications. FINDINGS: The best MLA was an ensemble algorithm of support vector machine, random forest classifier, gradient boosting classifier, logistic regression, and neural network algorithms, which achieved 100% determinate classifications (95% CI 100·0-100·0), an AUROC score of 0·870 (95% CI 0·797-0·931) on the TLC validation set (fibrosis stages F0 and F1 vs F4), and an AUROC of 0·716 (95% CI 0·664-0·766) on the MUHC validation set (fibrosis stages F0, F1, and F2 vs F3 and F4). The ensemble MLA outperformed all routinely used biomarkers and achieved comparable performance to hepatologists as measured by AUROC and percentage of indeterminate classifications in both the TLC validation dataset (APRI AUROC score 0·719 [95% CI 0·611-0·820], 83·7% determinate [95% CI 76·0-90·4]; FIB-4 AUROC score 0·825 [95% CI 0·730-0·912], 72·1% determinate [95% CI 63·5-80·8]) and the MUHC validation dataset (APRI AUROC score 0·618 [95% CI 0·548-0·691], 75·5% determinate [95% CI 71·5-79·2]; FIB-4 AUROC score 0·717 (95% CI 0·652-0·776), 75·5% determinate [95% CI 0·713-0·797]), and achieving only slightly lower AUROC than transient elastography (0·773 [95% CI 0·699-0·834] vs 0·826 [95% CI 0·758-0·889]). INTERPRETATION: We have shown that an ensemble MLA outperforms non-imaging-based methods in detecting advanced fibrosis across different causes of liver disease. Our MLA was superior to APRI, FIB-4, and NFS with no indeterminate classifications, while achieving performance comparable to an independent panel of experts. MLAs using routinely collected data could identify patients at high-risk of advanced hepatic fibrosis and cirrhosis among patients with chronic liver disease, allowing intervention before onset of decompensation. FUNDING: Toronto General Hospital Foundation.

Abdominal tuberculosis in a tertiary care centre in Saudi Arabia.

OBJECTIVES: Abdominal tuberculosis (ATB) is the second most common type of extra-pulmonary tuberculosis. Though it does not usually pose a significant risk of infectivity, ATB can go unidentified and progress to disseminated infection. The aim of this study is to highlight the incidence and outcome of this infection in a tertiary care centre in the Kingdom of Saudi Arabia (KSA). METHODS: In this retrospective study, we included all ATB patients admitted to our centre between January 1 st, 2010 and December 31, 2018. A total of 42 patients with a median age of 49 (range 18-83 years, 78.6% males) were identified. RESULTS: The most common presentation was abdominal pain, weight loss, and abdominal distension. All the patients were HIV negative; however, 50% had a comorbid condition, mainly diabetes mellitus, chronic renal failure, and liver cirrhosis. Tuberculous peritonitis was the predominant type of ATB. Suspicious and potentially malignant abdominal masses appeared on the abdominal CT scans of six patients. This suggest that TB should be excluded in patients from endemic area presenting with abdominal masses. All patients received standard anti-tuberculous medication for an average duration of 7.4 months. The outcome was excellent with 88%% achieving complete response. Adjunctive corticosteroids were not used, and none of the patients had a surgical complication. CONCLUSION: The diagnosis of ATB is challenging. It can mimic inflammatory bowel disease in young populations and malignancy in middle-aged and elderly population. For this reason, a high index of suspicion with prompt treatment is required to improve the prognosis and prevent complications.

Clinicopathologic characteristics andoutcomes of hepatocellular carcinoma associated with chronic hepatitis B versus hepatitis C infection.

BACKGROUND: Hepatocellular carcinoma (HCC) is a primary liver malignancy and one of the most common cancers worldwide. Few studies in Saudi Arabia have compared the clinicopathologic characteristics of HCC caused by hepatitis B virus (HBV) versus hepatitis C virus (HCV) and their effect on patient survival and prognosis. OBJECTIVES: Identify differences in clinicopathological characteristics and outcomes of hepatocellular carcinoma (HCC) caused by HBV versus HCV. DESIGN: A retrospective medical records review. SETTING: Tertiary medical center in Riyadh. PATIENTS AND METHODS: We included all new cases of HCC with underlying HBV and HCV infection diagnosed between January 2013 and September 2017 that met inclusion criteria. MAIN OUTCOME MEASURES: Clinical, biochemical, pathological and radiological characteristics, and survival differences were compared between HCC that developed in HBV- and HCV-infected patients. SAMPLE SIZE: Of 253 patients evaluated, 172 patients were included in the study. RESULTS: Of the 172 patients, 110 (64%) had HCV-associated HCC and 62 (36%) had HBV-associated HCC. More patients with HBV infection were males (P=.003) and were younger (P=.015) than HCV patients. HCV-infected patients who developed HCC had more advanced cirrhosis (P=.048). The prevalence of comorbidities and pre-existing cir.rhosis was similar in both groups. Seven patients (6.8%) with underlying HCV developed HCC in the absence of cirrhosis. Patients with HBV-associated HCC were less likely to meet Milan criteria at initial diagnosis than those with HCV-associated HCC (33.9% vs. 52.7%, respectively, P=.017). HBV-associated HCC occurred at a more advanced Barcelona Clinic Liver Cancer stage. The overall median survival and treatment outcome for each modality was comparable. CONCLUSIONS: HBV- and HCV-associated HCC have distinct clinical and pathological characteristics, necessitating different screening policies to optimize HCC surveillance and management. However, viral etiology did not affect the treatment outcome and long-term survival. LIMITATIONS: Conducted in a single-center, retrospective and lacks information about the use of antiviral treatment. CONFLICT OF INTEREST: None.

Clinical Presentation, Risk Factors, and Treatment Modalities of Hepatocellular Carcinoma: A Single Tertiary Care Center Experience.

Objective. To investigate the risk factors, clinical characteristics, treatment modalities, and outcomes in Saudi patients with HCC and propose points for early detection of the disease. Methods. Patients were stratified according to underlying risk factors for the development of HCC. Barcelona Clinic Liver Cancer (BCLC) was used for cancer staging. Treatment was classified into surgical resection/liver transplantation; locoregional ablation therapy; transarterial embolization; systemic chemotherapy; and best supportive care. Results. A total of 235 patients were included. Males had higher tumor size and incidence of portal vein thrombosis. Viral hepatitis was a risk factor in 75.7%. The most common BCLC stages were B (34.5%) and A (33.6%), and the most common radiological presentation was a single nodule of less than 5 cm. Metastases were present in 13.2%. Overall, 77 patients (32.8%) underwent a potentially curative treatment as the initial therapy. The most commonly utilized treatment modality was chemoembolization with 113 sessions in 71 patients. The overall median survival was 15.97 ± 27.18 months. Conclusion. HCC in Saudi Arabia is associated with high prevalence of HCV. Potentially curative therapies were underutilized in our patients. Cancer stage BCLC-B was the most frequent (34.5%) followed by BCLC-A (33.6%). The overall median survival was shorter than other studies.

Large-Cell Neuroendocrine Carcinoma of the Esophagus: A Case from Saudi Arabia.

Neuroendocrine carcinomas of the esophagus are very rare, and the majority are high grade (poorly differentiated). They occur most frequently in males in their sixth and seventh decades of life. There have been no concrete data published on clinical features or on prognosis. We report a case of large-cell neuroendocrine carcinoma of the esophagus in a 66-year-old Saudi female with progressive dysphagia and weight loss. Upper endoscopy revealed an esophageal ulcerated mass.

Competency-structured case discussion in the morning meeting: enhancing CanMEDS integration in daily practice.

Outcome-focused, competency-based educational curricula have become the norm in residency training programs. The Canadian Medical Education Directives for Specialists (CanMEDS) framework is one example of such a curriculum. However, models for incorporating all the competencies in everyday clinical practice have been difficult to accomplish. In this manuscript, a CanMEDS, competency-structured, acute case discussion in a regular morning meeting was undertaken. All the diagnostic and therapeutic interventions were explicitly organized and discussed under their respective CanMEDS competency headings. Post exercise, the majority of residents felt that they were more competent in all the competencies and indicated their willingness to continue having similarly structured acute case discussions in the future.