Outcomes and Predictors of Mortality in Patients With Drug-Induced Liver Injury at a Tertiary Hospital in South India: A Single-Centre Experience.

INTRODUCTION: Drug-induced liver injury (DILI) is an important cause of acute liver failure with significant morbidity and mortality. The outcome of DILI varies widely according to the drug implicated and the type of liver injury. Owing to the heterogeneous nature of liver injury, knowledge on clinical course and prognosis of DILI is limited. We had undertaken this study to determine the clinical characteristics, outcomes, and predictors of mortality in patients with DILI. MATERIALS AND METHODS: This prospective study was conducted from January 2015 through December 2018. We analyzed the drugs implicated, clinical course, and the outcome. Causality assessment was performed by using Roussel Uclaf Causality Assessment Method scoring. Patients were followed for 6 months until recovery/death or liver transplantation. RESULTS: There were 133 cases with DILI. The mean age was 47.6 years, and 51.9% of them were men. Drugs causing DILI were antitubercular drugs (37.5%) followed by neuropsychiatric drugs (16.5%), antibiotics/antifungals (12%), complementary and alternative medicine (10.5%), immunomodulatory/chemotherapeutic drugs (10.5%), and nonsteroidal antiinflammatory drugs (7.5%). Eighty-two (61.6%) patients were classified as hepatocellular, 30 (22.5%) as mixed and 21 (15.7%) as cholestatic type of injury. There was no significant difference in the mortality and morbidity between the three types of liver injury. There were 18 deaths (13.5%), of which antitubercular drugs constituted the majority (55.5%) followed by neuropsychiatric drugs (27.7%) and complementary and alternative medicine (16.6%). Based on receiver operating characteristic curve analysis, model for end-stage liver disease (MELD) score >28, mean international normalized ratio (INR) >1.97, mean bilirubin level >15.6 mg/dl, and creatinine level >1.35 mg/dl were associated with mortality. CONCLUSION: Although DILI is uncommon, it has significant morbidity and mortality. Antitubercular drugs were the most common cause for DILI and DILI-related mortality in our study. Variables such as MELD, INR, bilirubin, albumin, and creatinine help in predicting severity of liver injury and may help in triaging the patient for referral for liver transplantation.

Krukenberg tumour as the initial presentation of Peutz-Jeghers syndrome.

Peutz-Jeghers syndrome (PJS) is an hereditary syndrome characterized by gastrointestinal polyposis and mucocutaneous pigmentation. PJS patients are at increased risk of developing various cancers, especially of the gastrointestinal and gynaecological tracts. Colonic adenocarcinoma is one of the more common tumours that occur in PJS. We report a young lady presenting with a large ovarian tumour, later diagnosed to have PJS with colonic signet cell adenocarcinoma and synchronous ovarian metastasis.

Scrub typhus meningitis in South India--a retrospective study.

BACKGROUND: Scrub typhus is prevalent in India although definite statistics are not available. There has been only one study on scrub typhus meningitis 20 years ago. Most reports of meningitis/meningoencephalitis in scrub typhus are case reports. METHODS: A retrospective study done in Pondicherry to extract cases of scrub typhus admitted to hospital between February 2011 and January 2012. Diagnosis was by a combination of any one of the following in a patient with an acute febrile illness--a positive scrub IgM ELISA, Weil-Felix test, and an eschar. Lumbar puncture was performed in patients with headache, nuchal rigidity, altered sensorium or cranial nerve deficits. RESULTS: Sixty five cases of scrub typhus were found, and 17 (17/65) had meningitis. There were 33 males and 32 females. Thirteen had an eschar. Median cerebrospinal fluid (CSF) cell count, lymphocyte percentage, CSF protein, CSF glucose/blood glucose, CSF ADA were 54 cells/µL, 98%, 88 mg/dL, 0.622 and 3.5 U/mL respectively. Computed tomography was normal in patients with altered sensorium and cranial nerve deficits. Patients with meningitis had lesser respiratory symptoms and signs and higher urea levels. All patients had received doxycycline except one who additionally received chloramphenicol. CONCLUSION: Meningitis in scrub typhus is mild with quick and complete recovery. Clinical features and CSF findings can mimic tuberculous meningitis, except for ADA levels. In the Indian context where both scrub typhus and tuberculosis are endemic, ADA and scrub IgM may be helpful in identifying patients with scrub meningitis and in avoiding prolonged empirical antituberculous therapy in cases of lymphocytic meningitis.

Chronic diarrhea as the presenting complaint of systemic lupus erythematosus in a man.

Systemic lupus can involve any part of the gastrointestinal (GI) tract. Diarrhea generally results from complications arising from infection, drugs or pancreatitis. We herein report the case of a 40-year-old hypertensive man with a psychotic disorder in whom the evaluation of chronic diarrhea revealed a diagnosis of systemic lupus erythematosus (SLE), diffuse proliferative glomerulonephritis and protein-losing enteropathy that required treatment with both steroids and mycophenolate mofetil. Over the following year, the patient developed atrial fibrillation, miliary tuberculosis and generalized clonic tonic seizures. He is currently under regular follow-up care and receives antiepileptics, antihypertensives, diltiazem, amiodarone and warfarin.

Pancreatitis and MODS Due to Scrub Typhus and Dengue Co-Infection.

We report a 40 year old woman admitted with an acute abdomen. Investigations revealed pancreatitis, bilateral pleural effusion, renal failure, disseminated intravascular coagulation, and scrub IgM ELISA and dengue NS1 positivity. She improved with azithromycin and appropriate pain and fluid management. She also developed central venous catheter-related MRSA sepsis that was managed in the hospital.

Pulmonary edema in near hanging.

AIM: To study the incidence and outcome of pulmonary edema in patients admitted with near hanging. MATERIALS: A retrospective analysis of 19 cases of near hanging admitted in our Emergency Department between January 2007 and December 2010 was performed. Occurrence of pulmonary edema; electrocardiographic changes; ejection fraction on echocardiography, cardiac enzymes, mechanical ventilation; and use of inotropes, mannitol, and steroids were noted. RESULTS: Seven patients developed clinical and radiologic pulmonary edema, among whom three had electrocardiographic and echocardiographic changes that resolved before discharge. Use of mannitol precipitated edema in four, while inotropes and mechanical ventilation were instituted in three patients. CONCLUSION: Pulmonary edema can be due to neurogenic, cardiogenic, postobstructive causes or an interplay of the three. Takotsubo cardiomyopathy/myocardial stunning related pulmonary edema seems more common than the others. Pulmonary edema occurred irrespective of level of consciousness or electrocardiographic changes and was not associated with mortality. Victims of near hanging with pulmonary edema can be effectively treated with supportive therapy.

Yellow jacket envenomation-related acute renal failure.

We report a 58-year-old man with multiple yellow jacket stings who developed urticaria, renal failure, quadriparesis, rhabdomyolysis in succession. Investigations revealed renal and hepatic dysfunction, proteinuria, demyelinating polyradiculoneuropathy, acute tubular necrosis and glomerulonephritis. He improved with methylprednisolone, antihypertensives and two sessions of haemodialysis.