Severe jaundice with life-threatening liver failure after Kratom use: Reversed by plasma exchange.

Kratom is an herbal supplement which is used for its stimulating properties and pain reduction due to interaction with opioid receptors. Kratom overdose may cause fatality. A 56-year-old man was admitted to the emergency department with severe jaundice and liver failure. His total bilirubin reached at 70.6 mg/dL, but extensive workup did not show any liver mass. Family informed that the patient was taking Kratom. Plasma exchange was suggested as an unconventional therapy and consent from the patient was obtained because this procedure has never been performed to treat Kratom toxicity before. After four procedures, his total bilirubin was reduced to 23.9 mg/dL and his clinical condition improved significantly. Finally on day 5 he was discharged at stable condition with a total bilirubin value of 21.3 mg/dL. There is no antidote for Kratom, and treatment is supportive. To our knowledge this is the first report of reversing Kratom poisoning using plasma exchange.

Wearable Photomedicine for Neonatal Jaundice Treatment Using Blue Organic Light-Emitting Diodes (OLEDs): Toward Textile-Based Wearable Phototherapeutics.

Neonatal jaundice is a very common disease in newborns and can lead to brain damage or death in severe cases. Phototherapy with light-emitting diode (LED) arrays is widely used as the easiest and fastest way to relieve jaundice in newborns, but it has distinct disadvantages such as loss of water in the patient, damage to the retina, and separation from parents. In this paper, a novel light source-based phototherapy for neonatal jaundice is proposed using a textile-based wearable organic light-emitting diode (OLED) platform that can move flexibly and conform to the curvature of the human body. The soft and flexible textile-based blue OLED platform is designed to have a peak wavelength of 470 nm, suitable for jaundice treatment, and shows performance (>20 µW cm-2 nm- 1 ) suitable for intensive jaundice treatment even at low voltage (<4.0 V). The textile-based OLEDs fabricated in this study exhibit an operating reliability of over 100 h and low-temperature operation (<35 °C). The results of an in vitro jaundice treatment test using a large-area blue OLED confirm that the bilirubin level decreases to 12 mg dL-1 with 3 h of OLED irradiation.

Association between Serum Erythrocyte Immune Function Indexes and Blue Light Treatment or the Severity of PJON.

BACKGROUND: The association between serum erythrocyte immune function indexes and blue light treatment effect and severity in child patients with pathological jaundice was testified. METHODS: One hundred and seven children with pathological jaundice and 69 children with physiological jaundice were enrolled to analyze the association between erythrocyte immune function indexes and blue light treatment or disease progression. RESULTS: The area under the ROC curve (AUC) of red blood cell immune complex rosettes (RBC-ICR) and red blood cell C3b receptor rosette (RBC-C3bR) in diagnosing pathological jaundice and assessing the efficacy of blue light therapy overweighed 0.8. Meanwhile, the RBC-ICR values of the child patients were positively correlated with the severity of the disease, and the RBC-C3bR and red blood cell immune affinity receptor (FEER) values were negatively correlated with them (p < 0.05). CONCLUSIONS: The erythrocyte immune function indexes of child patients with pathological jaundice were relevant to the disease severity, and was provided with diagnostic value for pathological jaundice or assessed value for the efficacy of blue light therapy.

Effects of Tuina on newborns with jaundice: A meta-analysis.

BACKGROUND: The impact of Tuina on neonatal jaundice is not yet comprehensively understood, and its clinical application is rather limited. This study systematically assessed the relevant literature and conducted a meta-analysis to study the influence of Tuina on neonatal jaundice and provide convincing clinical evidence for promoting its clinical application. METHODS: We searched Pubmed, Embase, Cochrane Library, CNKI, Wanfang, CQVIP, and CBM from the establishment of the database up to July 2021. Studies that are randomized controlled trials were included. However, duplicate publications; manuscripts with no full text, incomplete information, or inability to extract data; animal experiments; and reviews and systematic reviews were excluded. STATA 15.1 was used to analyze the data. RESULTS: The pooled results showed that compared with the treatment of neonatal jaundice solely with blue light, Tuina combined with blue light significantly improved the total effective rate and frequency of defecation on days 1, 2, 3, 4, and 5 and significantly decreased the traditional Chinese medicine syndrome score; the third serum total bilirubin on days 3, 4, and 7; and duration of jaundice. Moreover, the incidence of adverse events in neonatal jaundice treated with Tuina combined with blue light was significantly lower than that with blue light alone. CONCLUSION: Tuina combined with blue light for treating neonatal jaundice can increase the effect of clinical treatment and reduce the adverse events caused by blue light therapy. Thus, the clinical application of traditional Chinese medicine Tuina in neonatal jaundice should be further promoted.

MGE-Like Neural Progenitor Cell Survival and Expression of Parvalbumin and Proenkephalin in a Jaundiced Rat Model of Kernicterus.

Kernicterus is a permanent condition caused by brain damage from bilirubin toxicity. Dystonia is one of the most debilitating symptoms of kernicterus and results from damage to the globus pallidus (GP). One potential therapeutic strategy to treat dystonia in kernicterus is to replace lost GP neurons and restore basal ganglia circuits through stem cell transplantation. Toward this end, we differentiated human embryonic stem cells (hESCs) into medial ganglion eminence (MGE; the embryological origin of most of the GP neurons)-like neural precursor cells (NPCs). We determined neurochemical phenotype in cell culture and after transplanting into the GP of jaundiced Gunn rats. We also determined grafted cell survival as well as migration, distribution, and morphology after transplantation. As in the GP, most cultured MGE-like NPCs expressed γ-aminobutyric acid (GABA), with some co-expressing markers for parvalbumin (PV) and others expressing markers for pro-enkephalin (PENK). MGE-like NPCs survived in brains at least 7 weeks after transplantation, with most aggregating near the injection site. Grafted cells expressed GABA and PV or PENK as in the normal GP. Although survival was low and the maturity of grafted cells varied, many cells produced neurite outgrowth. While promising, our results suggest the need to further optimize the differentiation protocol for MGE-like NPC for potential use in treating dystonia in kernicterus.

Zieve syndrome presenting with lipaemia and treated by plasmapheresis.

Zieve syndrome is a rare condition which occurs in patients with severe alcohol abuse. It is typically characterised by the triad of jaundice, haemolytic anaemia and transient hyperlipidaemia. In the following report, we present the case of a man in his 30s who was admitted to our emergency department with severe epigastric pain and signs of alcohol intoxication. Blood samples showed signs of severe hyperlipidaemia and jaundice. Due to massive hyperlipidaemia, laboratory measurements of triglycerides were impaired and the blood samples had a 'yellowish' and 'creamy' texture. In order to prevent pancreatitis, plasmapheresis was performed. Subsequently, triglyceride concentration dropped and the patient was discharged a few days later in significantly improved physical condition. In the following case report, we discuss plasmapheresis as a possible treatment for patients with severe Zieve syndrome in addition to conventional symptomatic therapy.

Clinical Profile and Outcome Following Exchange Transfusion for Neonatal Jaundice in a Tertiary Care Centre.

INTRODUCTION: Phototherapy has reduced the need for exchange transfusion (ET) to manage jaundiced neonates. Hence there are concerns about increased risk of complication due to lack of opportunity to sustain skills in performing ET. We studied the complications and treatment outcomes of neonates treated for jaundice with ET. METHODOLOGY: A retrospective observational study was conducted from June 2013 to June 2020 in a tertiary care hospital in India. All neonates treated with ET for jaundice were included. RESULTS: Twenty-eight neonates underwent 31 ET during the study period. Their mean gestational age and birth weight were 37 weeks and 3200 g, respectively. Predisposing factor for jaundice observed were Coomb's positive status (11), hepatosplenomegaly suggesting hemolysis (3), cephalhematoma (2) and birth asphyxia (1). Abnormal neurological status before ET was seen in seven neonates. Adverse clinical events that happened during or within 8 h after ET were desaturation (4), tachycardia (3), tachypnea (2), bradycardia (2), shock (2) and temperature instability (2). One neonate developed acute kidney injury after ET and required peritoneal dialysis. Abnormal lab parameters observed during or within 8 h after ET were hypocalcemia (20), anemia (8), hypokalemia (7), hypernatremia (3), thrombocytopenia (3) and hyperkalemia (2). Post ET sepsis was seen in five neonates: two had only blood culture positive sepsis, two had bone and joint infection and one had liver abscess. CONCLUSION: The neonates undergoing ET are at high risk of developing complications which may be life threatening. Hence careful monitoring during the procedure is needed.

Exchange transfusion is a treatment done for newborn babies with severe jaundice. This procedure is done by removing baby's blood in small quantities and replacing it with donor's blood. This life-saving procedure is associated with many complications. We did this study to estimate the complications associated with this procedure in our newborn unit. Twenty-eight patients underwent exchange transfusion from June 2013 to June 2020 in our hospital. We found out that temperature disturbance, abnormal heart rate, abnormal breathing and fall in oxygen levels occurred during exchange transfusion. After the procedure blood circulation disturbances, low platelet count, low blood calcium levels and low blood potassium levels were commonly observed. One patient developed renal failure after the procedure and was treated with dialysis. Five patients developed infection after the procedure and were treated with antibiotics. Thus newborn patients undergoing exchange transfusion are at high risk of developing complications which may be life threatening. Hence careful monitoring during the procedure is needed to prevent these complications.

Fifteen-minute consultation: Baby with jaundice in the first 2 weeks of life.

There are multiple causes of jaundice in the first 2 weeks of life. The aim of this article is to help explain what these causes are and why they occur. It discusses how to focus on the history, examination and investigations in such cases. Initial management will vary depending on the clinical context; as such, this article also outlines the initial management of the most common scenarios.

Jaundice as a Diagnostic and Therapeutic Problem: A General Practitioner's Approach.

BACKGROUND: Jaundice is a common clinical finding in clinical practice of hepatologists and general practitioners. It occurs when serum bilirubin levels exceed 3 mg/dL. SUMMARY: In this review, we summarize the pathophysiological mechanism of jaundice, clinical approach to the patient with jaundice, and laboratory and imaging techniques. Clinical presentation of jaundice manifests through yellow skin and sclera coloration. Evaluation of every patient includes detailed medical history and examination. In the laboratory, evaluation of enzymes of hepatic inflammation as well as cholestatic enzymes with serum bilirubin must be included. Additional laboratory analysis and imaging modalities are needed in order to differentiate jaundice etiology. Moreover, imaging is available and needed in further evaluation, and treatment is dependent on the underlying cause. KEY MESSAGES: In this review, we will outline the pathophysiological mechanism of jaundice, clinical approach to the patient with jaundice, and diagnostic and treatment approach to these patients.

Biliary Atresia/Neonatal Cholestasis: What is in the Horizon?

"Biliary atresia (BA) is a common cause of jaundice in infancy. There is increasing evidence that newborn screening with direct or conjugated bilirubin leads to earlier diagnosis. Although the Kasai portoenterostomy is the primary treatment, there are scientific advances in adjuvant therapies. As pediatric patients transition to adult care, multidisciplinary care is essential, given the complexity of this patient population."

Cholangiopathy After Severe COVID-19: Clinical Features and Prognostic Implications.

INTRODUCTION: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 virus, is a predominantly respiratory tract infection with the capacity to affect multiple organ systems. Abnormal liver tests, mainly transaminase elevations, have been reported in hospitalized patients. We describe a syndrome of cholangiopathy in patients recovering from severe COVID-19 characterized by marked elevation in serum alkaline phosphatase (ALP) accompanied by evidence of bile duct injury on imaging. METHODS: We conducted a retrospective study of COVID-19 patients admitted to our institution from March 1, 2020, to August 15, 2020, on whom the hepatology service was consulted for abnormal liver tests. Bile duct injury was identified by abnormal liver tests with serum ALP > 3x upper limit of normal and abnormal findings on magnetic resonance cholangiopacreatography. Clinical, laboratory, radiological, and histological findings were recorded in a Research Electronic Data Capture database. RESULTS: Twelve patients were identified, 11 men and 1 woman, with a mean age of 58 years. Mean time from COVID-19 diagnosis to diagnosis of cholangiopathy was 118 days. Peak median serum alanine aminotransferase was 661 U/L and peak median serum ALP was 1855 U/L. Marked elevations of erythrocyte sedimentation rate, C-reactive protein, and D-dimers were common. Magnetic resonance cholangiopacreatography findings included beading of intrahepatic ducts (11/12, 92%), bile duct wall thickening with enhancement (7/12, 58%), and peribiliary diffusion high signal (10/12, 83%). Liver biopsy in 4 patients showed acute and/or chronic large duct obstruction without clear bile duct loss. Progressive biliary tract damage has been demonstrated radiographically. Five patients were referred for consideration of liver transplantation after experiencing persistent jaundice, hepatic insufficiency, and/or recurrent bacterial cholangitis. One patient underwent successful living donor liver transplantation. DISCUSSION: Cholangiopathy is a late complication of severe COVID-19 with the potential for progressive biliary injury and liver failure. Further studies are required to understand pathogenesis, natural history, and therapeutic interventions.

Endovascular Treatment of Aberrant Splenic Artery Aneurysm Presenting With Painless Progressive Jaundice: A Case Report and Literature Review.

Splenic artery (SA) originating from the superior mesenteric artery is a rare condition, and aneurysms in relation to this aberrant SA are even rarer. We reported the case of a 67-year-old female who presented with painless progressive jaundice for 2 months accompanied by thrombocytopenia and liver dysfunction. The computed tomographic angiography (CTA) showed an aberrant SAA located behind the pancreatic head along with the dilation of common bile duct. Stent-graft deployment in SMA and coil embolization of the aneurysm were performed. Her liver dysfunction and thrombocytopenia improved postoperatively. CTA at 2-year follow-up showed patency of stent-graft and SMA and the shrinkage of the excluded aneurysm sac. Considering the particular location of the aneurysm, painless progressive jaundice can be the initial symptom for the aberrant SAAs. This combined endovascular technique completely excluded the aneurysm and was beneficial for treating secondary liver dysfunction and thrombocytopenia.

Earlier Nutrient Fortification of Breastmilk Fed LBW Infants Improves Jaundice Related Outcomes.

This study aimed to evaluate jaundice outcomes of low-birthweight premature infants commenced on earlier versus later nutrient supplementation (80 mL/kg/day vs. 160 mL/kg/day; total fluid intake, F80 vs. F160). Demographics, feeding regimens, and clinical outcomes data were collected. Infant and maternal characteristics were similar. Earlier nutrient supplementation was associated with multiple improved jaundice outcomes: total (TSBR), unconjugated and conjugated (CSBR) serum bilirubin values (196 ± 46 vs. 228 ± 52, 184 ± 44 vs. 212 ± 50, 12 ± 4 vs. 16 ± 5, respectively, all p < 0.001); phototherapy (39% vs. 64%, p < 0.0001). % CSBR/TSBR ratio was similar between groups. For those on phototherapy, duration and median irradiance were similar. F80 infants experienced reduced: feeding intolerance (26.0% vs. 45.2%, p = 0.007); length of stay (16.0 ± 0.64 vs. 18.8 ± 0.74 days, p = 0.03), maximum weight loss as % birth weight (5% vs. 6%, p = 0.03); decrease in weight Z-score at 10 days (-0.70 ± 0.03 vs. -0.79 ± 0.03, p = 0.01). F80 infants regained birthweight earlier (10.0 ± 0.3 days vs. 11.5 ± 0.3 days, p < 0.0001) and had no differences in adverse clinical outcomes. We speculate that earlier nutrient supplementation improved jaundice outcomes due to enhanced excretion/elimination of bilirubin.

Concomitant Existence of Paroxysmal Nocturnal Hemoglobinuria in a Patient with Hb E (HBB: c.79G>A) Trait.

Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired clonal disorder that manifests with bone marrow failure, thrombosis and hemolysis. We present a 28-year-old male who presented with weakness, jaundice and transfusion dependence. On initial investigation, he was found to have anemia with jaundice with hemoglobin (Hb) capillary zone electrophoresis suggestive of Hb E (HBB: c.79G>A) trait. The same anomaly was also found in his mother. However, transfusion requirement was an unusual feature in the patient. As his corrected reticulocyte count was raised along with lactate dehydrogenase (LDH), which was suggestive of a hemolytic process, he was worked-up for the same. However, the direct Coombs test was negative. A bone marrow aspiration and biopsy was done to rule out hypersplenism but it revealed erythroid hyperplasia with reduced iron stores despite normal ferritin and iron studies. This was unusual as the patient had anemia requiring transfusions. He had no history of hemoglobinuria but a PNH by flowcytomety revealed a large clone of 81.2% in granulocytes and 88.5% in monocytes. The patient was started on Danazol and steroids for anemia which improved. He was counseled for matched sibling stem cell transplant. He had a full match with his brother. At the time of this study he awaits his transplant.

Risk factors for readmission for phototherapy due to jaundice in healthy newborns: a retrospective, observational study.

BACKGROUND: The guidelines of the American Academy of Pediatrics (AAP) for monitoring neonatal jaundice recommend universal postnatal screening for hyperbilirubinemia within 48 h from discharge. We observed that neonate with low-risk jaundice were more likely to be readmitted to hospital for phototherapy compared to neonate with high-risk jaundice. The aim of this study was to identify additional factors that increase the risk for jaundice-related readmission. METHODS: This observational case-control study was performed on 100 consecutive neonates with jaundice who were readmitted to hospital for phototherapy treatment and were compared to 100 neonates with jaundice during hospitalization who were not readmitted after discharge. The data retrieved from the medical records of all participants included maternal characteristics, delivery type and noteworthy events, gestational age at delivery, birth weight and weight loss, neonate physical findings, Apgar scores, laboratory findings, length of hospital stay, and administration of phototherapy during hospitalization. The length of time since discharge and readmission for jaundice was also recorded. RESULTS: The risk of readmission decreased by 48% [odds ratio (OR) =0.52; 95% confidence interval (CI) 0.341-0.801] with every day added to the original hospitalization stay, and by 71% (OR = 0.29; 95% CI 0.091-0.891) if phototherapy had been administered during postnatal hospitalization. In contrast, the risk increased by 28% (OR = 1.28; 95% CI 1.164-1.398) with every elevation by 1% in hematocrit, and by 2.78 time (95% CI 1.213-6.345; p = 0.0156) when the delta in infant weight was > 5% (the difference between birth weight and weight at discharge during the postnatal hospitalization). CONCLUSIONS: The risk factors for readmission, such as substantial weight loss (> 5% difference between birth and discharge) and elevated hematocrit should be taken into account in the decision to discharge neonate with low-risk jaundice. The AAP guidelines for decreasing readmission rates of neonatal jaundice by postnatal screening for hyperbilirubinemia alone may be more appropriate for neonate with high-risk jaundice.

Hepatitis E as a cause of adult hospitalization in Bangladesh: Results from an acute jaundice surveillance study in six tertiary hospitals, 2014-2017.

In the absence of reliable data on the burden of hepatitis E virus (HEV) in high endemic countries, we established a hospital-based acute jaundice surveillance program in six tertiary hospitals in Bangladesh to estimate the burden of HEV infection among hospitalized acute jaundice patients aged ≥14 years, identify seasonal and geographic patterns in the prevalence of hepatitis E, and examine factors associated with death. We collected blood specimens from enrolled acute jaundice patients, defined as new onset of either yellow eyes or skin during the past three months of hospital admission, and tested for immunoglobulin M (IgM) antibodies against HEV, HBV and HAV. The enrolled patients were followed up three months after hospital discharge to assess their survival status; pregnant women were followed up three months after their delivery to assess pregnancy outcomes. From December'2014 to September'2017, 1925 patients with acute jaundice were enrolled; 661 (34%) had acute hepatitis E, 48 (8%) had hepatitis A, and 293 (15%) had acute hepatitis B infection. Case fatality among hepatitis E patients was 5% (28/589). Most of the hepatitis E cases were males (74%; 486/661), but case fatality was higher among females-12% (8/68) among pregnant and 8% (7/91) among non-pregnant women. Half of the patients who died with acute hepatitis E had co-infection with HAV or HBV. Of the 62 HEV infected mothers who were alive until the delivery, 9 (15%) had miscarriage/stillbirth, and of those children who were born alive, 19% (10/53) died, all within one week of birth. This study confirms that hepatitis E is the leading cause of acute jaundice, leads to hospitalizations in all regions in Bangladesh, occurs throughout the year, and is associated with considerable morbidity and mortality. Effective control measures should be taken to reduce the risk of HEV infections including improvements in water quality, sanitation and hygiene practices and the introduction of HEV vaccine to high-risk groups.

Plants used for the treatment of icterus (jaundice) in Central India: A review.

Jaundice is one of the most common medical condition affecting infants, children, and adults. Jaundice is not a disease but it is a visible sign and symptom of liver disease which occurs when there is an increase in the amount of bilirubin circulating in the blood due to the abnormal metabolism and excretion in the urine. Medicinal plants are being used long ago by our ancestors for the treatment of jaundice. At the present era, consumption of these herbal medicines is increasing at a high speed, due to its less or no side effect and cost-effectiveness as compared to synthetic medicines. This review describes approximately 55 medicinal plants which are used by rural and tribal people of different area of Chhattisgarh for curing jaundice. The data was collected from different kinds of literature survey from the year 1993 to 2018. This review has been conferred in a systematic way which includes plant's vernacular name, botanical name along with its family, part used and ethnomedicinal uses in a tabulated form and also the description of scientific evidence behind the folklore uses of some medicinal plants along with their mechanism of action which have been reported in different kinds of literature. The current study may be useful for the development of new medicines for the treatment of jaundice.

Biliary atresia combined with progressive familial intrahepatic cholestasis type 3: A case report and review of the literature.

RATIONALE: Neonatal cholestasis is one of the most serious diseases in infancy. Progressive familial intrahepatic cholestasis (PFIC) is a disease that leads to intrahepatic cholestasis. It is one of the common causes of neonatal cholestasis in addition to biliary atresia (BA). The differential diagnosis of neonatal cholestasis is clinically challenging for pediatricians. PATIENT CONCERNS: A 4-month-old female presented with severe jaundice, pruritus, and pale stool for 20 days. Abnormally strong echoes near the portal area, an abnormally small gallbladder with an irregularly stiff wall, and splenomegaly were identified on abdominal ultrasound. Blood tests showed elevated alanine aminotransferase, total bilirubin, conjugated bilirubin, gamma-glutamyltranspeptidase, and total bile acid levels. DIAGNOSIS: Intraoperative cholangiography showed BA. ABCB4 gene mutation IVS13+6G>A/G was confirmed by genetic testing. The patient was diagnosed with BA combined with PFIC3. INTERVENTIONS: Kasai portoenterostomy and ursodeoxycholic acid were used for treatment. OUTCOMES: Her clinical symptoms and blood tests improved gradually. No recurrence was noted during 1 year of follow-up. LESSONS: Additional examinations, such as genetic testing, should be considered in patients with BA who had refractory jaundice after Kasai portoenterostomy in order to exclude intrahepatic cholestasis.