Atypical Intrahepatic Cholestasis of Pregnancy: A Red Herring.

Intrahepatic cholestasis of pregnancy is an intrahepatic etiology of acute cholestasis commonly defined by pruritus and increased bile acids, liver transaminases, and, occasionally, bilirubin. Azathioprine is an immunosuppressive agent associated with various forms of hepatoxicity, ranging from transient rises in serum aminotransferase levels, acute cholestatic injury, and chronic hepatic injury. In this report, we present a 20-year-old pregnant woman who presented with cholestatic liver injury due to intrahepatic cholestasis of pregnancy with a clinical picture complicated by increased levels of azathioprine metabolites.

Warfarin genotyping with hybridization-induced aggregation on a poly(ethylene terephthalate) microdevice.

Warfarin, a commonly prescribed oral anticoagulant, is burdened by a narrow therapeutic index and high inter-individual variability in response, making it the second leading cause of drug-related emergency room visits. Since genetic factors contribute significantly to warfarin sensitivity, a genotype-guided dosing strategy may reduce the occurrence of adverse events. While numerous methods have been demonstrated for warfarin genotyping, the specifications of most assays with respect to turnaround time and cost are not ideal for routine testing. Here, we present a unique method for warfarin genotyping based on multiplex PCR coupled with Hybridization-induced Aggregation (HIA), a bead-based technique for sequence-specific detection. A multiplex allele-specific PCR reaction was used to generate products corresponding to 3 genetic variants associated with warfarin sensitivity [CYP2C9 *2, CYP2C9 *3, and VKORC1 (1173C>T)] and an internal control product. The products were detected simultaneously on a poly(ethylene terephthalate) (PeT) microdevice using HIA, which provided genotyping results in approximately 15 minutes following PCR. The genotyping results of 23 patient DNA samples using this approach were in 100% concordance with the results of a validated test (WARFGENO test, ARUP laboratories). Additionally, the PCR reaction was successfully transferred to a PeT chip, which provided accurate genotyping results from patient DNA samples in under an hour. This work demonstrates a simple, rapid, and affordable approach to warfarin genotyping based on multiplex allele-specific PCR coupled with HIA detection. By demonstrating both chemistries on PeT microdevices, we show the potential for integration on a single device for sample-to-answer genotyping.