Liver failure after Bacillus cereus food poisoning,an underrecognized entity:A case report

BACKGROUND Bacillus cereus(B.cereus)is known to cause 2 types of foodborne diseases;the diarrheal and emetic syndromes.They are largely underreported due to their usually self-limiting course.Rare and sometimes fatal cases of liver failure,pulmonary hemorrhage and cerebral oedema have been reported mainly in children and young adults.We present here a case of liver failure associated with B.cereus food poisoning in a middle-aged patient.CASE SUMMARY A 48-year-old female patient presented to the emergency department for emesis,diarrhea,chills without fever,asthenia and diffuse abdominal cramps that started less than 30 minutes after eating a rice salad.Her past medical history was relevant for cholecystectomy and a cured Hashimoto’s disease.She did not take any medication,drugs and declared a consumption of one glass of wine per week.In the emergency department,she was treated with acetaminophen,metoclopramide,ondansetron,and an intravenous normal saline infusion.Blood gas analysis revealed a metabolic acidosis with hyperlactatemia,coagulation revealed a low prothrombin activity[32%;normal values(N):70-140]and a low Factor V activity(15%;N:>70).Transaminases were elevated with hyperbilirubinemia,elevated lipase and rhabdomyolysis.N-acetylcysteine treatment was introduced.Abdominal echography revealed no signs of chronic hepatopathy or hepatomegaly.Day after the admission,psychomotor activity improved,transaminases and lipase started decreasing.Rhabdomyolysis gradually worsened to peak on day 3.Screening tests for liver disease were negative for viral and autoimmune cause of liver failure.Stools cultures were positive for colonies of the B.cereus group which were also identified in the rice salad samples processed whereas blood cultures were negative.The patient’s condition improved gradually including her liver function parameters and psychomotor activity which allowed her discharged home on day 9.CONCLUSION We describe a rare case of hepatocellular dysfunction due to a foodborne B.cereus intoxication in an adult patient.Even if it is uncommon,the severity of liver dysfunction reported and mechanism of the cereulide toxin toxicity on liver suggest that acetaminophen should be avoided in case of a foodborne intoxication and n-acetylcysteine could be a potential therapy helping to prevent hepatocytes necrosis due to the oxidative stress induced by mitochondrial dysfunction.

Collagen proportionate area correlates to hepatic venous pressure gradient in non-abstinent cirrhotic patients with alcoholic liver disease

AIM To explore the relationship between collagen proportionate area(CPA) and portal hypertension-related clinical manifestations in alcoholic liver disease(ALD).METHODS Retrospective study with chart review of patients with ALD adressed to our center between January 2012 and December 2013 for a transjugular liver biopsy(TJLB) and hepatic hemodynamic study. Patients were included if they met the following criteria:(1) Medical indication for a liver biopsy in the setting of ALD;(2) recent(< 15 d) clinical, radiological, endoscopic and biological data available; and(3) estimated follow-up of at least 6 mo. Liver tissue from cirrhotic subjects obtained from transjugular liver biopsies was stained with Picro Sirius red and computer-assisted digital image analysis to determine fibrosis density using CPA was performed. RESULTS We included 61 patients with alcoholic ALD, subdivided in 41 active alcohol drinkers and 20 durably abstinent patients. Nine healthy liver donors served as controls. Mean CPA in patients with ALD was 7.1%, with no difference between active drinkers and abstinent patients(P = 0.17). Using a fibrosis density cutoff of 5%, we observed a positive correlation between high fibrosis density and the hepatic venous pressure gradient(HVPG) only in active drinkers(P = 0.02). At 12-mo of follow-up, in the group of active alcohol drinkers, patients reaching a composite outcome showed a higher HVPG value as compared to those who did not(18.5 mm Hg vs 14.5 mm Hg P < 0.04) whereas CPA values were similar(6.9% vs 11%, P = 0.23).CONCLUSION In active alcoholic ALD, CPA correlates to portal pressure but only HVPG predicts clinical events, pointing to the role of alcohol as a modulator of portal hypertension.

Molecular prognostic prediction in liver cirrhosis

The natural history of cirrhosis varies and therefore prognostic prediction is critical given the sizable patient population. A variety of clinical prognostic indicators have been developed and enable patient risk stratification although their performance is somewhat limited especially within relatively earlier stage of disease. Molecular prognostic indicators are expected to refine the prediction,and potentially link a subset of patients with molecular targeted interventions that counteract poor prognosis. Here we overview clinical and molecular prognostic indicators in the literature,and discuss critical issues to successfully define,evaluate,and deploy prognostic indicators as clinical scores or tests. The use of liver biopsy has been diminishing due to sampling variability on fibrosis assessment and emergence of imaging- or lab testbased fibrosis assessment methods. However,recent rapid developments of genomics technologies and selective molecular targeted agents has highlighted the need for biopsy tissue specimen to explore and establish molecular information-guided personalized/stratified clinical care,and eventually achieve "precision medicine".

Recent advances in gastrointestinal cancers

Gastrointestinal cancers occur in a total of eight different locations,each of them with a different standard of care.This article is not an exhaustive review of what has been published in 2020.We have concentrated on the thirteen phase III randomized studies that are practice-changing.All these studies are oral presentations which have been given in one of the four major oncology congresses,namely American Society of Clinical Oncology(ASCO),ASCO gastrointestinal(GI),European Society of Medical Oncology(ESMO)and ESMO-GI.We provide a concise view of these major trials and their main outcomes,and put these results into context.

Impact of direct-acting antivirals on the recurrence of hepatocellular carcinoma in chronic hepatitis C

Chronic hepatitis C virus(HCV)infection is estimated to affect 56.8 million individuals globally and is a major and independent risk factor for the development of hepatocellular carcinoma(HCC).After the introduction of safe and potent direct-acting antivirals(DAAs),capable of curing HCV infection also in patients with advanced liver disease at high risk of HCC,the beneficial effect on a de novo HCC development after viral clearance has been established.However,studies addressing the relationship between DAA-induced eradication and risk of HCC recurrence(i.e.,reappearance of HCC treated before starting antivirals)have produced contradictory data,suggesting either an increase or a decrease of HCC recurrence rate,while some report no effect of these treatments.Thus,there seems to be an unclear benefit of viral clearance in patients with a history of HCC curative treatment,where the recurrence rate remains worryingly high.This short review aims to summarize current evidence on the impact of DAAs on HCC recurrence rates,the pathogenic mechanisms and characteristics of HCC recurrence after DAA treatment,the predictors of tumor recurrence,and the impact of DAAs on overall survival.