Severe Hepatotoxicity in Mushroom Poisoning by Lepiota brunneoincarnata from Complete Recovery to Liver Transplantation: A Case Series with Review on Liver Function Tests and Liver Histopathology.

Background: In spite of the scientific evidence supporting health advantages of mushrooms, some of them are seriously poisonous. The clinical picture of mushroom intoxication ranges from minor gastrointestinal symptoms to organ failure, such as liver failure and death. Method: We provided demographics, clinicopathological characteristics, applied treatments, and outcomes of mushroom poisoning by Lepiota species in a series of 18 cases that were referred from Kermanshah and Lorestan provinces to Abu-Ali-Sina Hospital, Shiraz, Iran. Clinical and paraclinical data were collected by taking history and reviewing of medical documents. Pathologic findings were extracted through a review of hematoxylin and eosin pathologic slides. Results: The patients were between the ages of 18 and 67 years, composed of ten females and eight males. The most frequent clinical manifestations were nausea and vomiting followed by abdominal pain. Four cases presented decreased consciousness on admission. One of them passed away. Three other cases underwent liver transplantation, two of them died after transplantation, and one fully recovered without any major issues. All instances had elevated ALT levels, which ranged from 44 to 9,140 IU/L (mean: 3259 ± 2476), with most of them also having concurrent AST elevations (mean: 1,361 ± 1,532). Only few patients had modest elevations in alkaline phosphatase. Total and direct bilirubin elevations up to 47.6 and 24 mg/dL, respectively, were found in most cases. Decreased total protein and albumin concentrations and increased BUN and creatinine levels were observed in some patients. In addition, some instances revealed increased LDH, increased WBC, decreased hemoglobin, and decreased platelet count. Most patients had increased prothrombin time; hematuria and positive stool occult blood were observed in few patients. Histopathologic examination of three explanted livers revealed massive necrosis with moderate to severe macrovesicular steatosis, significant ductular reaction, and parenchymal inflammation. Other patients followed a recovery process with a considerable drop in liver enzymes, especially ALT, during hospitalization utilizing conservative treatment. They had no liver problems or relevant issues after a two-year follow-up. Conclusion: In our study, highly elevated liver enzymes with a significantly high ALT/AST ratio were observed in cases of mushroom poisoning by Lepiota species, leading to fulminant liver failure and death in some cases. These laboratory findings were correlated with liver necrosis and macrovesicular steatosis in explanted livers.

Critical value in surgical pathology: evaluating the current status in a multicenter study.

BACKGROUND: The concept of critical value is not evident in surgical pathology, and there is no established protocol for determining, reporting, and documenting these results. MATERIALS AND METHODS: A questionnaire was designed regarding critical value in surgical pathology, and all pathologists and some clinicians from five laboratories were asked to participate through an invitation link. The most important items were selected, and all pathologists were instructed to follow a standard operating procedure to deal with critical results for a year. RESULTS: A total of 43 pathologists and 44 non-pathologists participated in the study. Some critical or unexpected items were selected. Most participants agreed that the optimal time to announce critical reports is within 24 h of establishing the final diagnosis, and a phone call was the most dependable communication option. In addition, the most qualified recipients were the attending physicians. Therefore, a written policy was implemented for a year. One hundred seventy-seven critical or unexpected cases (0.5%) were detected. Mucormycosis and cytomegalovirus (CMV) were the most frequent critical cases. CONCLUSION: There are no set criteria for critical items or the reporting process in surgical pathology. It is possible to establish more uniform norms for reporting these cases by boosting pertinent research efforts and recruiting more pathologists and physicians. Additionally, it is advised that each medical facility compile its own unique critical or unexpected diagnosis list.

Termination of Repeat Testing in Chemical Laboratories Based on Practice Guidelines: Examining the Effect of Rule-Based Repeat Testing in a Transplantation Center.

BACKGROUND: Although the automation of instruments has reduced the variability of results and errors of analysis, in some laboratories, repeating a test to confirm its accuracy is still performed for critical and noncritical results. However, the importance of repeat testing is not well established yet, and there are no clear criteria for repeating a test. MATERIALS AND METHODS: In this cross-sectional study, all repeated tests for 26 biochemical analytes (i.e., albumin, alkaline phosphatase (ALP), alanine aminotransferase (ALT), amylase, aspartate aminotransferase (AST), bilirubin total (BT), bilirubin direct (BD), blood urea nitrogen (BUN), calcium, chloride (Cl), cholesterol total (CholT), creatine kinase (CK), creatinine (Cr), glucose, gamma-glutamyl transferase (GGT), high-density lipoprotein-cholesterol (HDL-c), iron, lactate dehydrogenase (LDH), LDL-c, lipase, magnesium (Mg), phosphorus (Ph), protein total (ProtT), total iron binding capacity (TIBC), triglyceride (TG), and uric acid) were assessed in both critical and noncritical ranges over two consecutive months (routine subjective test repeats in the first month and rule-based repeats in the second month). To determine the usefulness of test repeats, differences between the initial and verified results were compared with the allowable bias, and repeat testing was considered necessary if it exceeded the allowable bias range. All causes of repeat testing, including linearity flags, delta checks, clinically significant values, and critical values, were also documented. All data, including the cause of repeats, initial and verified results, time, and costs in the two consecutive months, were transferred to Microsoft Excel for analysis. For comparison of data between the months, Student's t-test was used. RESULTS: A total of 7714 repeat tests were performed over two consecutive months. Although a significant decline (38%) was found in repeated tests in the second month (P < 0.001), there was no significant change in the percentage of unnecessary repeats (77% in the first month and 74% in the second month). In both consecutive months, AST and ALT were the most commonly repeated tests, and delta check was the most common cause of repeat testing. Mg, ALP, AST, and lipase showed the highest rates of necessary repeats, respectively (the least stable tests), while albumin, LDL, and CholT tests showed the highest rates of unnecessary repeats, respectively (the most stable tests). The total cost and delay in turnaround time (TAT) due to repeated testing decreased by 32% and 36%, respectively. CONCLUSION: Although repeat testing has been shown to be unnecessary in most cases, having a strict policy for repeat testing appears to be more valuable than avoiding it completely. Each laboratory is advised to establish its own protocol for repeat testing based on its own practice.