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Terlipressin is an analogue of vasopressin and is often used in the treatment of bleeding esophageal varices and also in the treatment of hepatorenal syndrome associated with liver cirrhosis. Although terlipressin is a safe drug, but it has been rarely associated with potentially serious adverse effects like ischemic necrosis of skin involving the abdominal skin, extremities, and scrotal skin. We present one such rare case where terlipressin-induced skin necrosis in bilateral lower extremities in a 48-year-old male while we were managing hepatorenal syndrome in the same.

Finding the ideal balance between efficacy and safety of immunosuppression is challenging, particularly in cases of severe TAFRO syndrome. We herein report a 60-year-old man diagnosed with grade 5 TAFRO syndrome mimicking hepatorenal syndrome that was successfully treated by glucocorticoid, tocilizumab, and cyclosporin despite virus infection. Furthermore, by examining 14 peer-reviewed remission cases, we revealed that the recovery periods among inflammation, renal dysfunction, and thrombocytopenia were quite different, with recovery from thrombocytopenia notably slow. All patients requiring dialysis were successfully withdrawn from dialysis, and the reversibility from kidney injury was good. This clinical information will help clinicians plan treatments and tailor the intensity of immunosuppression.

Hepatorenal syndrome (HRS) was originally defined as a renal dysfunction caused by a decreased renal perfusion due to hemodynamic disturbances in the arterial circulation and an excessive activity of endogenous vasoactive systems in the course of cirrhosis. Considering the latest research, this syndrome may have a more complex pathomechanism. Equally often as in cirrhosis, HRS develops after orthotopic liver transplantation (OLTx) and worsens the prognosis significantly increasing mortality rates in this patient population. The prevalence of renal complications after OLTx and their negative prognostic impact on the survival of both the graft and the recipient prompted the authors of this work to analyze in detail 2 cases of HRS after OLTx to indicate the multiplicity of factors contributing to the pathophysiology of this syndrome. Attention was paid to risk factors for HRS found in the anamnesis before OLTx, especially a pre-existing renal dysfunction. In both cases early post-OLTx complications associated with the transplantation procedure were described: destabilization of the circulatory system, transfusions of blood products, prolonged stay at an intensive care unit, and necessity of introducing continuous renal replacement therapy. In the later period after the OLTx, infections (bacterial, fungal, viral) and drug nephrotoxicity, including the activity of immunosuppressants (tacrolimus), contributed primarily to the renal function impairment.

BACKGROUND: Terlipressin is widely used for treatment of hepatorenal syndrome and variceal bleeding in cirrhotic patients. However, it may be associated with side effects, especially those related to vasoconstriction, such as myocardial infarction or intestinal ischemia. This is a case report of a cirrhotic patient with nonvariceal upper gastrointestinal bleeding after duodenal necrosis due to the use of terlipressin, a novel side effect not yet described in literature to the best of our knowledge.
METHODS: A 51-year-old male patient, with alcoholic liver cirrhosis and hepatitis C virus infection, was admitted presenting oliguria associated with severe ascites and lower limb edema. His Model for End Stage Liver Disease-Sodium score was 19 and his serum creatine level was 2.12 mg/dL. Albumin infusion was performed for 48 hours, but his serum creatinine level reached 3.46 mg/dL. Terlipressin infusion was started in continuous infusion and serum creatinine levels progressively decreased. However, the patient presented hemorrhagic shock secondary to hematemesis after 7 days. Upper digestive endoscopy showed an extensive ulcerated lesion in the duodenal bulb, reaching 70% of its lumen, with hematic residues and necrotic foci. Terlipressin was suspended and proton pump inhibitors were started. Despite intensive care, the patient developed severe encephalopathy and reentrant seizures. He eventually died 10 days after the bleeding event.
CONCLUSIONS: We described a case of nonvariceal upper gastrointestinal bleeding secondary to duodenal necrosis, which was caused by visceral ischemia induced by terlipressin. Given its fatality potential, this novel side effect should be remembered when using this medication in cirrhotic patients.

HRS is a rare and poor prognosis complication of chronic acetaminophen toxicity, which presents by progressive decline in renal function secondary to liver failure.

As the world fights with the Coronavirus, most of the hospitals are gearing up for the care of these patients. As most of the attention these days is being given on Coronavirus, the patients suffering from other clinical infections are being neglected. SARS-CoV-2 is being kept as the top differential in patients presenting with fever and respiratory distress. We hereby present a case of patient returning from Indonesia during the pandemic presenting with a history of hepatic, renal dysfunction with fever and cough. Due to the pandemic, the patient\'s fever and cough outweighed the hepatic and renal dysfunction, and the patient had to undergo dialysis before the final diagnosis of leptospirosis could be made.

Leptospirosis is a zoonotic disease caused by spirochetal bacterial of the genus Leptospira affecting virtually all mammals. The infection has a broad range of effects, from mild clinical manifestation to multiple organ failure, and ultimately death. A 5-months-old male unvaccinated dog was admitted to the University Veterinary Teaching Hospital presenting dullness, dehydration, jaundiced mucous, bloody diarrhea, vomiting, and hyporexia. Microscopic agglutination test (MAT) detected serological titers of 1:1.600 for serogroup Canicola. After five days of monitoring by the medical team he developed fever and swelling of carpal and tarsal joints, accompanied by functional limitation. Initial antimicrobial treatment was instituted for leptospirosis. Polyarthritis responsiveness to glucocorticoid therapy was observed through decreasing signs of inflammation of the affected joints. The diagnosis of leptospirosis was further confirmed by molecular investigation for Leptospira spp. on blood and synovial fluid samples. Amplification and sequencing of the secY partial gene characterized the infective bacterial as Leptospira interrogans. From the 7th day the respiratory condition worsened and on Day 14 the patient evolved to death, when necropsy and histological evaluation were performed. Prominent anatomopathological findings included: fibrinous polyarthritis, bronchointerstitial pneumonia, intense hepatocyte dissociation, cholestasis, and periportal multifocal hepatitis, diffuse acute tubular necrosis, and significant dystrophic mineralization in the renal parenchyma, lungs, and atrial endocardium. Here, we present a case report of systemic clinical manifestations polyarthritis associated with the presence of leptospiras in the synovial fluid. We highlight the need for richer knowledge about the different clinical manifestations of leptospirosis.

Arteriovenous fistula (AVF) is a rare complication of the abdominal aortic aneurysm (AAA) with complex clinical features. However, AVF and AAA usually cause no symptoms except when they rupture. This case study demonstrated that ultrasonography was a rapid and non-invasive method for the initial assessment of AAA and AVF. A 65-year-old man was admitted to the intensive care unit with hepatic and renal dysfunction. Physical examination revealed an abdominal vascular murmur and bilateral toe discoloration. Ultrasonic examination revealed an AAA and right common iliac artery aneurysm with an AVF located between the right common iliac artery and inferior vena cava. A computed tomography scan confirmed the sonographic findings. We propose that ultrasound should be used more commonly as part of the initial evaluation of the potential and established vascular diseases.

BACKGROUND: Approximately 5000 species of wild mushroom are reported worldwide, of which 100 are documented as poisonous and <10 are fatal. The clinical picture of patients with wild mushroom intoxication depends mostly on the type of ingested mushroom, ranging from mild gastrointestinal symptoms to organ failure and death.
UNASSIGNED: We report 2 children, sister and brother admitted in our clinic for gastrointestinal symptoms: abdominal pain, nausea, vomiting, and diarrhea after wild mushroom ingestion.
METHODS: The laboratory tests revealed hepatic cytolysis syndrome, hyperbilirubinemia, impaired coagulation status, hypoalbuminemia, hypoglycemia, and electrolytic unbalances in both cases. Abdominal ultrasound showed hepatomegaly and ascites.
METHODS: After admission, both cases received penicillin by vein, activated charcoal, liver protectors, glucose, and electrolytes perfusions. Nevertheless, their status worsened and required the transfer to the pediatric intensive care unit for appropriate supportive measure. Therefore, therapeutic plasma exchange was initiated along with N-acetyl cysteine and hemostatic drugs.
RESULTS: Despite all these therapeutic interventions, both cases developed hepatorenal syndrome and died after a couple of days from ingestion.
CONCLUSIONS: Mushroom poisoning remains a public health problem in developing countries. Preventable strategies and education regarding the consumption of wild type mushrooms are essential for decreasing the morbidity and mortality rates in these areas.