Clinical Case Summary

The ubiquitous availability of digital media does not only have advantages. Inexperienced mushroom pickers increasingly frequently use APPs for mushroom identification and consume forest mushrooms with false security. Currently, for example, life-threatening Amanita phalloides poisoning is becoming more frequent.
A 65-year-old patient presented with a latency period of approximately 40 hours after consumption of the mushrooms. Nausea and vomiting, as well as loss of strength and cramps in arms and legs, had already been present for about 24 hours. Laboratory tests revealed coagulation failure and markedly elevated transaminases (INR 2.1, GOT 2590 U/l, GPT 3119 U/l). The Meld Score was 33. Only when asked explicitly the patient reported eating wild mushrooms he had collected. The vomit and mushroom debris were recovered and immediately examined by a mushroom expert. Immediately after admission to our intensive care unit, liver protective therapy with Silibinin and N-Acetylcysteine was initiated.
Analysis by a fungal expert revealed evidence of Amanita phalloides. At an INR of 3.3 with massive diffuse skin hemorrhages and rising transaminases (GOT 4825U/l, GPT 4104U/l), repeated therapeutic plasma exchange (exchange of 1.3 times the plasma volume) was performed to control the complications of liver failure. In the course, transaminases and coagulation parameters stabilized, and liver transplantation was not necessary. The patient is now in excellent general health.
Our patient case shows that early diagnosis, as well as therapy, are crucial to reducing the lethality of tuberous leaf fungus poisoning. Patients are often unaware of the danger, so if they have symptoms, they should be asked explicitly about consuming collected mushrooms. As a bridging therapy for the stabilization and regeneration of liver function, therapeutic plasma exchange is an excellent option.

Disclosure

No conflicts of interests

Introduction

Cirrhosis is a chronic condition with a high mortality. Cirrhotic patients with portal hypertension frequently present with large esophageal varices with bleeding or need for endoscopic intervention. The choice of treatment for variceal hemorrhage is endoscopic ligation and beta-blockers, which can be used as secondary prophylaxis. The pleiotropic effects of statins have been reported for the treatment of cardiovascular diseases, but at the liver level they favor the reduction of the hepatic venous pressure gradient (HVPG), with a decrease in the number of variceal hemorrhage events; however, their use had been restricted in cirrhotic patients due to their association with elevations in liver biochemistries.

Aims & Methods

To evaluate the safety statins in cirrhotic patients with an indication for high cardiovascular risk. And as a secondary aim, determine the presence of variceal hemorrhage during follow-up. This retrospective cohort study was carried out by the "Centro Médico Nacional 20 de Noviembre" between 2018 to 2022. Child Pugh A and B cirrhotic patients with a history of variceal hemorrhage or large varices with endoscopic ligation intervention without active hemorrhage were included and observed over a period of 4 years. To determine adverse events, compatible clinical data and biochemical examinations were searched in the electronic record, and pharmacovigilance committee records were reviewed.

Results

A total of 106 patients were included, of which 53 with statin use and 53 without statins. The characteristics were 41.5% men (n=44), 58.5% women (n=62). The average age was 62 ± 10 years. In order of frequency, the causes were: cryptogenic 25.5% (n=27), hepatitis C virus (HCV) 21.7% (n=23), primary biliary cholangitis (PBC) 14.2% (n=15), metabolic dysfunction-associated fatty liver disease (MAFLD) 13.2% (n=14), alcohol 12.3% (n=13), autoimmune hepatitis (AIH) 11.3% (n=12), hepatitis B virus (HBV) 1.9% (n= 2). With Child Pugh A 67% (n=71) Child Pugh B 35% (n=33). In the statin and non-statin group, the average values of the following variables were PT 12.7 ±1.9 vs 14 ±2.2, AST 39.6 ±24 vs 61 ±40, ALT 37.6 ±28 vs 51 ±38, albumin 3.8 ±0.6 vs 3.6 ±0.5, total cholesterol 157.6 ±35 vs 179.4 ±68, INR 1.06 ±0.17 vs 1.1 ±0.18 (p=< 0.05) (Table 1). In the group of patients with statin use in 18.4% (n=10) Variceal ligation was performed, and in the group without statins, 24.5% (n=13), with a RR of 1.075, 95% CI (0.8-1.3). In the group of patients with statin use, 9.5% (n=5) had a bleeding event, and in the group without statins, 7.5% (n=4) had a bleeding event, with an RR of 1.25, CI 95% (0.3-4.4). None of the participants had clinical adverse effects.

Table 1. Demographics, selected clinical characteristics, and outcomes of patients

Conclusion

The use of statins in cirrhosis compensated with portal hypertension was safe. In this study we could not demonstrate the pleiotropic effect of statins, probably due to the sample size. Therefore, it is necessary to generate subsequent studies including a larger number of patients.

Disclosure

The authors declare that they have no conflict of interest.

Introduction

Contrast-enhanced harmonic endoscopic ultrasound (CEH-EUS) can demonstrate microvascularization of the tumors. However, most images acquired from CEH-EUS are interpreted subjectively without quantification by time-intensity curves (TICs) analysis. The role of quantitative CEH-EUS through time-intensity curve (TIC) has not been explored in differential diagnosis of gallbladder(GB) polypoid lesions.

Aims & Methods

Aim: In this study, we used a handcrafted software to quantify TIC curve of CEH-EUS images to differentiate malignant gallbladder polypoid lesions from benign ones.
Method: We analyzed the videos of CEH-EUS for GB polypoid lesions from the patients in National Taiwan University Hospital. The convex-type echoendoscope (GF-UCT260; Olympus, Tokyo, Japan) equipped with ultrasound (US) systems (EU-ME2) was used for the procedures. The second generation of US contrast agent with Sonazoid (GE Healthcare, Oslo, Norway), which contains perfluorobutane microbubbles with a median diameter of 2–3 μm, was administered bolus and intravenously with a dosage of 0.015 ml encapsulated gas per kilogram body weight. The videos were recorded in AVI formats with 30 frames/second.
The algorithm for getting TICs includes the following steps:
(1) Circling the region of interest(ROI) in the B-mode
(2) Performing speckle tracking of the ROI in the B-mode
(3) Simultaneously obtaining the intensity of ROI (the mean pixel values in the ROI) in the corresponding contrast-enhanced harmonic image
(4) Outputting TICs after subtracting the baseline intensity (for eliminating the different baseline intensities caused by other settings).
(5) Outputting histogram of pixel values and excel file containing all pixel values from the frame with the highest mean pixel value automatically.
(6) Calculating the standard variance of (5) to represent the heterogeneity inside the ROI.
The speckling tracking composes of searching and matching processes. We used full search for the searching process and normalization cross-correlation for the matching process. By using the hardware of CPU with Intel i7-8750H and GPU with Nvidia GTX 1050 Ti, the computation time was 0.7 ms/frame. Based on this algorithm, we designed a graphical user interface of this model.

Results

A total of 30 eligible videos were enrolled for analysis. Fourteen lesions were pathologically proven of malignancies (including 11 adenocarcinomas, two neuroendocrine tumors, one B-cell lymphoma) and the other 16 lesions were benign cases. Among 16 benign lesions, 6 were chronic cholecystitis, 4 were adenomyoma, 2 were intracholecystic papillary neoplasm, one was xanthogranulomatous cholecystitis, one was cholesterol polyps, one was hyperplastic polyp and one was Mycobacterium tuberculosis. The lesion size ranged from 8.1 to 90mm in malignant group and from 4.4 to 29mm in benign group. The mean peak intensity was 46.36 dB (SD=31.77) in malignant group and 55.94 dB (SD=44.59) in benign group respectively (p=.509). The mean time to peak was 30.14 s (SD=10.00) in malignant group and 20.50 s (SD=6.70) in benign group respectively (p=.004).

Conclusion

This preliminary report of using TIC of CEH-EUS images for differential diagnosis of GB polypoid lesions showed significant difference in time to peak between malignant group and benign group. Further large scale of studies are needed for comfirming the application of this novel technique.

Disclosure

Conflict of Interest