A 72 year-old-patient without known past medical history presented to the hospital with worsening cough, dyspnea on exertion, decreased appetite, weight loss for two months. Prior to admission, he was treated with a 10- day course of levofloxacin and prednisone as a case of bronchitis with minimal improvement. Then he started to develop red urine with marked changes in mental status. On physical examination, the patient had notifiable scleral icterus, confusion and abdominal tenderness in the right upper quadrant. On admission his labs were significant for alkaline phosphatase 541, aspartate transaminase 557, alanine transaminase 94, total bilirubin 8.6, lactate 11.7. CT scan of abdomen showed hepatosplenomegaly, mild ascites and trace bilateral pleural effusion. Work up with Viral hepatitis serology, cryptococcal antigen, histoplasma antigen, respiratory virus panel, Epstein Barr virus tests were negative. Anti-nuclear antibodies (ANA) and anti-mitochondrial antibody were also negative. Blood level of amylase, lipase, acetaminophen and alcohol were negative at admission too. The patient was started initially on broad spectrum antibiotics, N-acetyl cysteine empirically and aggressive intravenous fluid hydration. Patient condition rapidly worsened and he developed profound shock requiring mechanical ventilation and started on stress dose steroid and pressor support. Upon further investigation, patient was noted to take terbinafine for toe onychomycosis (day 112). Ferritin level was elevated to 1596 with 93% iron saturation. Ceruloplasmin level was normal. Patient was not a transplant candidate due to multiple organ failure. As per family request, patient was palliatively extubated and died. Terbinafine is a fungicidal drug with activity against dermatophytes including Epidermophyton flccosum and trichophyton rubrum. It works by inhibition of squalene epoxidase with a resultant accumulation of squalene in the fungal cell and killing it as a result. Commonly used orally to treat onychomycosis and other fingernails and toenails infections. Shortly after its introduction to the market, DILI had been reported with elevation with serum aminotransferases elevation that was usually self-limited. Usually presents within first 6 weeks of therapy with either hepatocellular or cholestatic initially with sings of hypersensitivity. Mechanism of injury entails hypersensitivity reaction, though the full pathogenesis was not elucidated yet, but genetic polymorphism is implicated in the variable presentation especially among HLA-A 33:01 allele carriers. Terbinafine DILI resolves usually within 6 months of stopping the medication but can lead to death or need liver transplantation in some cases.

Changes in lifestyle of people has been dynamically observed in recent decades, emphasis is given to dietary issues. In this case, as directly responsible for chronic diseases, along with other aspects of lifestyle such as inactivity, smoking, quality of life. In the context of chronic diseases of high incidence and prevalence, the metabolic syndrome has gained prominence in clinical and experimental research in the search for early diagnostic methods for its various components such as the vascular, biochemical and liver, all also associated with diet. In this context, there was the inclusion of non-alcoholic fatty liver disease as liver component of the metabolic syndrome, which is the central object of this work. Objective: To evaluate the profile morphological, functional and redox balance in the liver of a novel induced-diet mice model for metabolic syndrome. Methods: Eleven isogenic male C57BL/6J mice were randomly divided into control (CT) and hypercaloric (HC) groups and fed with chow and hypercaloric diet, respectively, for 26 weeks. We did ratings serum markers of liver function (ALT, AST, ALP, γ-GT, LDH, albumin and total protein), analysis of local redox status (SOD, CAT and lipid peroxidation) and histological study of tissue. Results: There were significant elevations of the statistical point of view in the main markers of liver function in HC animals. This increase was approximately 1.5 times for ALT, 2.5 for AST and 7.4 for ALP. The activity of γ-GT followed the pattern of significant increase in the HC group, despite its low activity. There re no differences in the concentrations of albumin and total protein. On the local redox state, the activity of SOD was not different between groups, the catalase activity was significantly decreased in HC group and there re high levels of peroxidation in this same group. The histological findings corroborate these results, which corresponds to advanced liver disease in animals HC (default cirrhotic). Conclusion: The hepatic component in the novel induced-diet mice model for metabolic syndrome shows changes in your profile functional, redox balance and morphological. Keywords: Metabolic Syndrome, Liver Functions, Redox Balance, Novel Diet-induced Mice Model. / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / As alterações no estilo de vida das pessoas vem sendo dinamicamente observadas nas últimas décadas; destaque especial é dado aos aspectos dietéticos. Neste caso, como responsável direto por doenças crônicas, juntamente com outros aspectos do estilo de vida como sedentarismo, tabagismo, qualidade de vida. No contexto das doenças crônicas de elevada incidência e prevalência, a síndrome metabólica vem ganhando destaque nas pesquisas experimentais e clínicas na busca de métodos diagnósticos precoces para seus vários componentes a exemplo dos vasculares, bioquímicos e hepáticos, todos com associação também dietética. Neste contexto, destaca-se a inserção das doenças hepáticas gordurosas não alcoólicas como componente hepático da síndrome, sendo este o objeto central do presente trabalho. Objetivo: Avaliar o perfil morfológico, funcional e o balanço redox do fígado de um novo modelo murino dietético para síndrome metabólica. Métodos: Onze camundongos isogênicos machos C57BL/6J foram randomicamente divididos nos grupos Controle (CT) e Hipercalórico (HC) e alimentados com dieta chow e hipercalórica, respectivamente, durante 26 semanas. Foram procedidas avaliações plasmáticas de marcadores de função hepática (ALT, AST, ALP, γ-GT, LDH, albumina e proteínas totais), análise do estado redox local (SOD, CAT e peroxidação lipídica) e estudo histológico do tecido. Resultados: Foram encontradas elevações significativas do ponto de vista estatístico nos principais marcadores de função hepática nos animais HC. Esse aumento foi de aproximadamente 1,5 vezes para ALT, 2,5 para AST e de 7,4 para ALP. A atividade de γ-GT seguiu o padrão observado de elevação significativa no grupo HC, apesar de sua baixa atividade. Não foram observadas diferenças nas concentrações de albumina e proteínas totais. Relativo ao estado redox local, a atividade de SOD não foi diferente entre os grupos, a de catalase foi significativamente diminuída nos HC e os níveis de peroxidação elevados. Os achados histológicos corroboram esses resultados, sendo corresponde a doença hepática avançada nos animais HC (padrão cirrótico). Conclusão: O componente hepático no novo modelo murino dietético para síndrome metabólica estudado apresenta alterações em seu perfil morfológico, funcional e no balanço redox.

The prevalence of Hepatitis C Virus (HCV) in the US is estimated at 3.5 million with 18,153 deaths in 2016. It is the most common bloodborne infection, with a higher age-adjusted mortality rate than Hepatitis B Virus or Human Immunodeficiency Virus. Without treatment, nearly 1.1 million people will die from HCV by 2060. About 41,200 new cases of HCV were reported in 41 states in the US in 2016. The reported cases of acute HCV in 2016 is 2.3 per 100,000 in Tennessee, which is more than twice the national goal set by Healthy People 2020. This is a descriptive study to ascertain the HCV prevalence and usefulness of screening in medical outreach settings (MO) compared to indigent healthcare clinics (IHC) in northeast Tennessee. This study period was from April 2017 – February 2019. Participants (n=250), were adults, who engaged in routine, opt-out HCV testing at 4 IHC and 3 MO sites in the Tri-Cities, TN region. During the screening, demographic information- age, gender, race- were collected and the de-identified data were analyzed using Statistical Analysis System (SAS 9.3) to perform a descriptive analysis. Also, several discrete Chi-Square tests of independence between the demographic variables, screening locations, and HCV antibody prevalence was conducted. A total of 250 clients were screened for HCV. The majority of clients screened were non-Hispanic whites 228 (91.20%); females 136 (54.40%); young adults 131 (52.40%) and at IHC clinics 187 (74.80%). Screening showed HCV antibody prevalence of 14.8%. The majority of positive cases were non-Hispanic whites 36 (97.30%; P=0.1561); females 19 (51.35%; P=0.6867) and young adults 23 (62.16%; P=0.286). The prevalence at the IHC clinics and MO settings were 36 (97.30%; P=0.0006) and 1(2.70%) respectively. This analysis shows the higher yield of targeted HCV screening at IHC clinics. Focused HCV screening is critical in the era of opioid epidemic, particularly when direct-acting antiviral agents (DAAs) which offer a Sustained Virologic Response (SVR) rate of more than 90% are available. The use of case control or cohort study designs to establish causality is recommended for improving focused HCV screening.