Unusual Facial Movements (Ictal Blinking, Oculogyric Crises, and Jaw Seizure) in Severe Liver Disease: A Case Series.

Background: Seizures are reported in about one-third of patients with severe liver disease in association with acute or chronic liver failure. The majority of the seizures are of focal type. Occasionally generalized tonic-clonic seizures are seen when there is ethanol withdrawal. Not much is known about ictal blinking (IB) in severe liver disease. IB is the rare form of seizures and was reported in severe liver disease recently from this institute. Oculogyric crisis (OGC) is rarely reported in relation to the severe liver disease. OGC was also noted first time in our intensive care unit. Methods: At the Institute of Liver and Biliary Sciences (ILBS), data on patients with IB and OGC were analyzed from October 2018 to January 2023 (52 months). All the patients had video electroencephalograph (video-EEG) recording after proper permission/consent. The patients were followed up later for the course of the illness. Results: A total of 16 (12M:4F) patients were seen. Majority 12 (75%) were IB and 3 OGC. EEG was abnormal in nine (75.0%) of IB patients. Brain imaging had nonspecific findings. The outcome was based on the severity and recovery of the underlying liver disease. Conclusions: Unusual facial movements in the form of IB and OGC are reported, which are most of the time missed. This report highlights the importance of recognition of these events and proper in time management to improve the outcome.

Herb-induced Liver Injury-A Guide to Approach. Lessons from the Tinospora cordifolia (Giloy) Case Series Story.

Background: Tinospora cordifolia (TC) is being increasingly consumed in India for its health and suggested immune-enhancing benefits in preventing and countering COVID-19. We previously published our experience of hepatotoxicity with self-medication of TC in six individuals. Since herb-induced liver injury (HILI) has been described with Tinospora crispa (TCR) consumption, it was contested that our patients may have mistakenly self-medicated with TCR which is similar in appearance to TC. Methods: We collected the four plant samples and two commercial preparations that were consumed by our patients for further analysis. The six samples underwent high performance thin layer chromatography phytochemical analysis and DNA barcoding studies for the confirmation of the genus and species. The four plant part samples which included stems and leaves were also analysed by a botanist for the characteristic morphological and microscopic features. Results: Based on morphological, microscopic, phytochemical and DNA studies, the four plant part samples were identified as TC. The two commercial preparations could not be analysed on phytochemical analysis or DNA barcoding studies due to other ingredients that most likely interfered with the analysis. The herb consumed by our study subjects was confirmed to be Tinospora cordifolia. Conclusion: We have highlighted the key morphological and phytochemical differences between these two species. We propose an algorithmic approach to accurately identify the implicated herb in cases of HILI. Future studies on causality need to focus on the serological/histopathological identification of active herb/metabolites in human tissues.

Decompensation of Cirrhosis: An Unusual Cause.

We describe a case of a 69-year-old woman, a known case of compensated Hepatitis C cirrhosis, presenting with recurrent urinary tract infection (UTI) secondary to Salmonella Paratyphi B. She had recently tested positive for Salmonella Paratyphi bacteremia associated with UTI, managed with antibiotics. Two weeks later, she presented with fever and burning micturition with signs of abdominal distension and pedal edema suggestive of decompensation of cirrhosis. She had repeat positive urine cultures for Salmonella and was managed with broad-spectrum antibiotics, surgical stone removal, and supportive measures leading to resolution of symptoms and ascites. She was administered a prolonged antibiotic course on discharge for chronic shedding of Salmonella in the urine. UTIs are a common cause of decompensation in immunosuppressed states like liver cirrhosis, and rare infections like salmonella need to be identified and managed appropriately with sensitive antibiotics and the right duration of treatment.

Cutaneous mucormycosis: an unusual cause of decompensation in a patient with ethanol-related cirrhosis with COVID-19 exposure.

We describe a case of cutaneous mucormycosis in a middle-aged man with ethanol-related chronic liver disease. He presented with symptoms of fever, breathlessness for 10 days and altered mental status for 2 days. On admission, he was in septic shock and had acute respiratory distress syndrome (ARDS). He was noted to have ruptured blisters in his left axilla. Although he repeatedly had negative COVID-19 Reverse Transcription-PCR results, he had positive IgG antibodies for COVID-19. He was managed with broad-spectrum antibiotics, steroids, vasopressors and ventilation for ARDS. Over the course of his hospitalisation, the axillary lesion progressed to a necrotising ulcer with deep tissue invasion. Debridement and culture of the axillary ulcer revealed mucor species, and he was started on amphotericin and posaconazole for mucormycosis. Unfortunately, he continued to deteriorate despite aggressive management and died after a prolonged hospital stay of 40 days.

Herbal Immune Booster-Induced Liver Injury in the COVID-19 Pandemic - A Case Series.

The COVID-19 pandemic has resulted in widespread use of complementary and alternative medicines. Tinospora cordifolia is a widely grown shrub which has been commonly used in India's traditional system of Ayurveda for its immune booster properties and has been extensively used as prophylaxis against COVID-19. Six patients (4 women, 2 men) with a median (IQR) age of 55 years (45-56) and with an history of Tinospora cordifolia consumption presented with symptoms of acute hepatitis during the study period of 4 months in the COVID-19 pandemic. The median (IQR) duration of Tinospora cordifolia consumption was 90 days (21-210). The median (IQR) peak bilirubin and AST were 17.5 mg/dl (12.2-24.9) and 1350 IU/ml (1099-1773), respectively. The patients had either a definite (n = 4) or probable (n = 2) revised autoimmune hepatitis score with an autoimmune pattern of drug-induced liver injury on biopsy. Four of these patients (all women) had underlying silent chronic liver disease of possible autoimmune etiology associated with other autoimmune diseases - hypothyroidism and type 2 diabetes mellitus. One of the three patients treated with steroids decompensated on steroid tapering. The other five patients had resolution of symptoms, liver profile, and autoimmune serological markers on drug withdrawal/continuing steroid treatment. The median (IQR) time to resolution from discontinuing the herb was 86.5 days (53-111). Tinospora cordifolia consumption seems to induce an autoimmune-like hepatitis or unmask an underlying autoimmune chronic liver disease, which may support its immune stimulant mechanism. However, the same mechanism can cause significant liver toxicity, and we recommend that caution be exercised in the use of this herb, especially in those predisposed to autoimmune disorders. Besides, in patients presenting with acute hepatitis, even in the presence of autoimmune markers, a detailed complementary and alternative medicine history needs to be elicited.