Optimizing surveillance of low-risk metabolic dysfunction associated steatotic liver disease using transient elastography.

BACKGROUND: Most people with metabolic dysfunction-associated steatotic liver disease (MASLD) lack significant fibrosis and are considered low-risk. Surveillance strategy for low-risk MASLD remains uncertain. AIM: Identify which low-risk subjects can avoid follow-up vibration-controlled transient elastography (VCTE) within 1 year. METHODS: Retrospective analysis of two independent low-risk MASLD cohorts (baseline liver stiffness [LS] < 8kPa) with routine 6-12 months follow-up VCTE. The primary outcome was LS ≥ 8kPa on follow-up, requiring referral and further work-up according to current guidance. Predictors of the primary outcome on univariate and multivariate logistic regression were incorporated into a decision algorithm, and validated in an independent cohort. RESULTS: Of 206 subjects in the derivation cohort, 96 were low-risk. After a median of 10 months, 24 (25%) low-risk subjects had LS ≥ 8kPa. Baseline LS ( P  < 0.01) and ALT change from baseline ( P  = 0.02) (multivariate AUROC = 0.84 [0.74-0.94]) predicted the primary outcome, and were incorporated to a two-step decision algorithm. Low-risk subjects with baseline LS < 5.5 kPa can avoid repeating VCTE in a year, while those with LS > 6.8 kPa require one. For intermediate baseline LS (5.5-6.8kPa), repeat VCTE is only indicated when ALT increase > 6 U/L. The algorithm had 92% negative predictive value, 78% specificity, and 78% accuracy in the derivation cohort. In the validation cohort (n = 64), it had 91% NPV, 72% specificity, and 71% accuracy. CONCLUSION: In low-risk MASLD, a simple algorithm combining baseline LS and ALT change can be used to safely avoid a repeat VCTE in a year.

Association between body mass index and liver stiffness measurement using transient elastography in patients with non-alcoholic fatty liver disease in a hepatology clinic: a cross sectional study.

Background: Transient elastography (TE) is an FDA approved, non-invasive tool to estimate liver stiffness measurement (LSM) in patients with non-alcoholic fatty liver disease (NAFLD). Our aim was to analyze if body mass index (BMI) would predict the severity of liver stiffness using TE scores. Methods: We performed a cross-sectional study of patients with NAFLD who presented to the hepatology clinic between January 2019 through January 2021. Fibrosis severity was divided into the following categories: F0 to F1 (2-7 kPa), F2 (>7 to 10 kPa), F3 (>10 to 14 kPa) and F4 (>14 kPa). We used ordered logistic regression models to determine the odds ratio (OR) and 95% confidence interval (CI) of having a higher LSM severity compared to lower associated with BMI. Models were adjusted for patient demographics and comorbidities. Results: Among 284 patients, 56.7% were females, and the median (interquartile range, IQR) age was 62 [51-68] years and BMI 31.9 (28.1, 36.2) kg/m2; 47% of patients were in the F0 to F1 stage, 24% F2, 16% F3, and 13% F4. The correlation between BMI and TE score was 0.31 (P<0.001). With 1 kg/m2 increase in BMI there was 1.10 times higher odds of having a higher LSM severity (adjusted OR, 1.10; 95% CI: 1.05-1.14). Compared to patients with BMI <25 kg/m2, the adjusted OR (95% CI) of having a higher fibrosis stage was 1.82 (0.61-5.44), 5.93 (2.05-17.13), and 8.56 (2.51-29.17) for patients with BMI of 25 to <30, 30 to <40, and ≥40 respectively. Conclusions: BMI correlates with the severity of LSM using TE scores in NAFLD patients even after adjusting for potential confounding variables. This suggests TE as an appreciable study for liver stiffness even in obese individuals.

Immensely High Creatine Kinase Levels in a Case of Rhabdomyolysis Due to Legionnaires' Disease in a Patient on Tofacitinib: A Case Report and Literature Review.

A 58-year-old female patient presented with altered mental status, diarrhea, and fever. She was hospitalized for acute kidney injury [AKI] and a patchy right lower lobe infiltrates on chest X-ray. Subsequent testing revealed rhabdomyolysis and a positive urinary Legionella antigen test. Creatinine kinase [CK] level peaked at 512,820 U/L and was managed with aggressive intravenous hydration and appropriate antibiotic treatment. With clinical signs of resolution of pneumonia, the CK level declined rapidly, however renal function returned to baseline only after 2 months requiring hemodialysis in the meantime. The patient was also on tofacitinib which can rarely contribute to rhabdomyolysis. Legionella infection can cause severe rhabdomyolysis and AKI. Timely diagnosis of Legionella-associated rhabdomyolysis, and prompt treatment with aggressive IV hydration and appropriate antibiotics is required to prevent morbidity and mortality.

Hemorrhagic pneumonia and upper lobe pulmonary cavitary lesion caused by Streptococcus pyogenes.

A 33-year-old previously healthy man from Mexico who presented with massive hemoptysis, fevers, chills and found to have cavitary lesions in the right upper lobe of lung was highly suspicious for tuberculosis. The patient was treated with vancomycin, ceftriaxone, azithromycin and placed on isolation for suspected tuberculosis. Sputum AFB stains were negative and blood cultures grew Group A Streptococcus [GAS]. Antibiotics were narrowed down to ampicillin-sulbactam and the patient was discharged with significant clinical improvement. Strep A pyogenes is a rare cause of cavitary hemorrhagic pneumonia but is associated with high mortality. Clinical suspicion and early diagnosis are crucial in saving the patient.

Parasitic necrotizing pneumonia in an immunocompetent patient in United States.

A 59-year-old Baltimore native female, with a history of asthma and no history of travel outside of the USA, presented with productive cough and shortness of breath. Computed tomography scan showed left upper lobe consolidation of the lung with multiple tiny cavitations. She was empirically treated without improvement. Later, strongyloides were found in the sputum gram stain and she was treated with ivermectin. Pulmonary strongyloidiasis has been mainly described in patients who are immunosuppressed and have a history of travel to endemic areas, both of which were absent in our patient. Our case underlines the importance of considering strongyloides necrotizing pneumonia as a differential diagnosis of community-acquired pneumonia even in immunocompetent patients in the USA, especially if not responding to empiric treatment.