Fatal outcome of a corticosteroid resistant IgG4-related autoimmune hepatitis and IgG4-primary sclerosing cholangitis.

33-year-old woman, previously hospitalized for self-limited migratory bile duct strictures, presented with jaundice three months after giving birth. Blood analysis revealed elevated levels of aspartate aminotransaminase 1064U/L, alanine aminotransaminase 1097U/L, gamma-glutamyl transferase 194U/L, alkaline phosphatase 284U/L, bilirubin 27mg/dL and prothrombin time of 19.3s. Magnetic resonance-cholangiopancreatography revealed intrahepatic bile duct dilation with a stenosis in the common hepatic duct, not detected on endoscopic retrograde cholangiopancreatography. Additionally, diffuse signal abnormalities were observed in the liver parenchyma on T2 sequences. An early liver biopsy showed moderate-severe interface hepatitis with IgG4-positive plasma cell infiltration (IgG4-PPC) of 8-20cells/HPF, hepatocellular ballooning and focal rosette formation, yielding 6 points of the simplified-score for autoimmune hepatitis and treatment with methylprednisolone was initiated. Despite treatment, there was no improvement after two weeks and the patient received rituximab as a rescue treatment, but three days later, developed candida sepsis with rapid progression to multiorgan failure, ultimately resulting in death.

Small intestinal bacterial overgrowth is common after gastrectomy but with little impact on nutritional status. / El sobrecrecimiento bacteriano de intestino delgado es una entidad frecuente tras gastrectomía, pero con escasa relevancia en el estado nutricional.

BACKGROUND: Available evidence assessing the impact of small intestinal bacterial overgrowth (SIBO) following gastrectomy is limited. OBJECTIVES: To evaluate the prevalence of SIBO after gastrectomy and its association with malnutrition. To describe the antibiotic treatment required to correct it and if nutritional status improves. MATERIAL AND METHODS: A prospective cohort study was performed at the Agencia Sanitaria Costa del Sol (Costa del Sol Health Agency) from 2012 to 2015. A hydrogen-methane breath test with oral glucose overload was performed. Demographic variables and nutritional parameters were collected at baseline and one month after effective treatment of SIBO. The antibiotic regimens and the number of treatment lines used were assessed. RESULTS: Sixty gastrectomy patients were analysed, 58.3% of which were male. A sub-analysis of the curve was performed at 45min to minimise possible false positives, and SIBO was identified in 61.6% of cases. SIBO patients tended to have a lower BMI, although this trend was not statistically significant. After treatment with rifaximin, 94.6% of patients were still positive for SIBO, which fell to 85.7% after metronidazole. The rate of total antibiotic treatment failure was 67.6%. No statistically significant changes were found in nutritional parameters after treatment. CONCLUSIONS: SIBO was identified in 61.6% of patients after gastrectomy. No correlation was found with any malnutrition parameter. Rifaximin and metronidazole were found to be largely ineffective in eradicating SIBO. When treatment was effective, the impact on malnutrition was negligible and may have been associated with other factors.

Reconstitution Inflammatory Syndrome Like Reactive Hemophagocytic Syndrome Associated with Disseminated Histoplasmosis in a HIV Patient.

We describe an unusual clinical association of disseminated histoplasmosis with reactive hemophagocytic syndrome. We report the case of a new HIV-positive patient with reconstitution inflammatory syndrome like reactive hemophagocytic syndrome associated with disseminated histoplasmosis. We describe the clinical case, the procedures performed, the treatment provided and the patient's evolution. A figure of liver biopsy Grocott's silver methenamine stain that shows lots of uniform ovoid yeasts in portal spaces' macrophages that supports the diagnosis of disseminated histoplasmosis in our case.

Colonic leishmaniasis in a patient with HIV: a case report.

BACKGROUND: To describe an unusual clinical presentation of visceral leishmaniasis affecting the colon. CASE REPORT: We report the case of an HIV-positive patient with visceral leishmaniasis. We describe the clinical case, the procedures performed, the treatment provided and the patient's evolution. A comparative table of previously reported similar cases is shown. DISCUSSION: Visceral leishmaniasis with intestinal involvement is an uncommon process. Nevertheless, this possibility should be taken into consideration in the differential diagnosis of immunosuppressed patients with symptoms of diarrhea, as a favorable prognosis depends on early diagnosis and appropriate treatment.