Liver steatosis in patients with rheumatoid arthritis treated with methotrexate is associated with body mass index

BACKGROUND Methotrexate(MTX)is the usual first-line treatment for rheumatoid arthritis(RA).Long-term use of MTX has been associated with liver steatosis(LS)and liver fibrosis(LF).AIM To determine if LS in patients treated with MTX for RA is associated with MTX cumulative dose(MTX-CD),metabolic syndrome(Mt S),body mass index(BMI),the male sex,or LF.METHODS A single-center,prospective study of patients receiving MTX for RA was performed from February 2019 to February 2020.The inclusion criteria were patients aged 18 years or older diagnosed with RA by a rheumatologist and being treated with MTX(without limitation on the duration of treatment).The exclusion criteria were previous diagnosis of liver disease(hepatitis B or C virus infection,known nonalcoholic fatty liver disease),alcohol consumption greater than 60 g/d in males or 40 g/d in females,human immunodeficiency virus infection on antiretroviral therapy,diabetes mellitus,chronic renal failure,congestive heart failure,or BMI greater than 30 kg/m^(2).Patients receiving leflunomide in the 3 years prior to the study were also excluded.Transient elastography(Fibro Scan,Echosens?,Paris,France)was used for fibrosis determination(LF>7 Kp A)and computer attenuation parameter(CAP)for LS(CAP>248 d B/m).Demographic variables,laboratory data,MTX-CD(>4000 mg),Mt S criteria,BMI(>25),transient elastography,and CAP scores were collected from all patients.RESULTS Fifty-nine patients were included.Forty-three were female(72.88%),and the mean age was 61.52 years(standard deviation:11.73).When we compared MTX-CD≤4000 mg(26 patients;14 with LS and 12 without)with>4000 mg(33 patients;12 with LS and 21 without),no statistical differences were found(P=0.179).We compared CAP scores stratified by Mt S,BMI,sex,and LF.There were no significant differences in CAP scores based on the presence of Mt S[CAP/Mt S:50 no Mt S(84.75%);9 Mt S(15.25%);P=0.138],the male sex(CAP/sex:8 male/18 female LS;8 male/25 female no LS;P=0.576),or LF[CAP/fibrosis:53 no LF(89.83%);6 LF(10.17%);P=0.239].LS determined by CAP was significantly associated with BMI>25(CAP/BMI:22 BMI≤25(37.29%);37 BMI>25(62.71%);P=0.002].CONCLUSION LS in patients with RA treated with MTX was not associated with MTX-CD,LF,the male sex,or Mt S.However,BMI was significantly related to LS in these patients.

drug-induced autoimmune liver disease:a diagnostic dilemma of an increasingly reported disease

The aetiology of autoimmune hepatitis(AIH) is uncer-tain but the disease can be triggered in susceptible patients by external factors such as viruses or drugs.AIH usually develops in individuals with a genetic back-ground mainly consisting of some risk alleles of the major histocompatibility complex(HLA).Many drugs have been linked to AIH phenotypes,which sometimes persist after drug discontinuation,suggesting that they awaken latent autoimmunity.At least three clini-cal scenarios have been proposed that refers to drug- induced autoimmune liver disease(DIAILD):AIH with drug-induced liver injury(DILI); drug induced-AIH(DI-AIH); and immune mediated DILI(IM-DILI).In addi-tion,there are instances showing mixed features of DI-AIH and IM-DILI,as well as DILI cases with positive autoantibodies.Histologically distinguishing DILI from AIH remains a challenge.Even more challenging is the differentiation of AIH from DI-AIH mainly relying in histological features; however,a detailed standard-ised histologic evaluation of large cohorts of AIH and DI-AIH patients would probably render more subtle features that could be of help in the differential diag-nosis between both entities.Growing information on the relationship of drugs and AIH is being available,being drugs like statins and biologic agents more fre-quently involved in cases of DIAILD.In addition,there is some evidence on the fact that patients diagnosed with DIAILD may have had a previous episode of hepa-totoxicity.Further collaborative studies in DIAILD will strengthen the knowledge and understanding of this intriguing and complex disorder which might represent different phenotypes across the spectrum of

Non-invasive methods for liver fi brosis prediction in hemochromatosis:One step beyond

Advances in recent years in the understanding of, and the genetic diagnosis of hereditary hemochromatosis (HH) have changed the approach to iron overload he-reditary diseases. The ability to use a radiologic tool (MRI) that accurately provides liver iron concentration determination, and the presence of non-invasive sero-logic markers for fibrosis prediction (ser um ferritin, platelet count, transaminases, etc), have diminished the need for liver biopsy for diagnosis and prognosis of this disease. Consequently, the role of liv er biopsy in iron metabolism disorders is changing. Furthermore, the irruption of transient elastography to assess liver stiffness, and, more recently, the ability to determine liver f ibrosis by means of MRI elastography will change this role even more, with a potential drastic decline in hepatic biopsies in years to come. This review will provide a brief summary of the different non-invasive methods available nowadays for diagnosis and prognosis in HH, and point out potential new techniques that could come about in the next years for fibrosis prediction, thus avoiding the need for liver biopsy in a greater number of patients. It is possible that liver biopsy will remain useful for the diagnosis of associated diseases, where other non-invasive means are not po-ssible, or for those rare cases displaying discrepancies between radiological and biochemical markers.

Cytomegalovirus hepatitis and myopericarditis

Cytomegalovirus (CMV) infection in inmunocompetent hosts generally is asymptomatic or may present as a mononucleosis syndrome but rarely can lead to severe organ complications. We report a case of simultaneous hepatic and pericardic CMV infection in a 36-year old immunocompetent man. He was admitted to coronary unit with fever, chest pain radiated to shoulders, changes on electrocardiogram with diffuse ST elevation and modest laboratory elevations in the MB fraction of creatine kinase (CK-MB) of 33.77 μg/L (0.1-6.73), serum cardiac troponin T of 0.904 ng/mL (0-0.4), creatine kinase of 454 U/L (20-195) and myoglobin of 480.4 μg/L (28-72). Routine laboratory test detected an elevation of aminotransferase level: alanine aminotransferase 1445 U/L, aspartate aminotransferase 601 U/L. We ruled out other causes of hepatitis with normal results except IgM CMV. The patient was diagnosed with myopericarditis and hepatitis caused by cytomegalovirus and started symptomatic treatment with salicylic acid. In few days the laboratory findings became normal and the patient was discharged.