Clinical vignette: Pyogenic liver abscess vs. hepatocellular carcinoma, the challenge of diagnosis without a biopsy

A liver mass in a cirrhotic liver should always raise the concern for hepatocellular carcinoma (HCC), and expert guidelines state that diagnosis can be made with imaging alone in some settings. Our case illustrates that care must be taken to consider other etiologies before making that diagnosis. A 57 year old man with alcoholic liver cirrhosis came to the ED complaining of 1 month of severe, intermittent abdominal pain with associated subjective fever and chills. A CT abdomen on admission reported 2 ill-defined hypodense liver lesions concerning for HCC. In the setting of liver cirrhosis and a hepatic mass, work up for HCC was initiated, including an AFP which was later found to be normal. IR was consulted for possible biopsy, however because the patient had an elevated INR and thrombocytopenia it was deferred and a triple phase MRI was instead recommended to further evaluation. Infection was initially lower on the differential due to lack of fever and normal WBC. On hospital day 2 one of the BCXs from admission revealed Streptococcus viridians (later updated to Strep milleri). On hospital day 3, fevers, tachycardia and leukocytosis developed. An abscess was now more likely. The patient was initially monitored without antibiotics, but after the positive culture and the episode of fever, he was started on ceftriaxone and a second set of BCX were drawn which later revealed the same organism. The MRI showed two rim enhancing lesions in the right hepatic lobe which in the setting of infectious symptoms, were favored to represent abscesses. ID was consulted and recommended 6 weeks of IV ceftriaxone. A TEE showed no evidence of endocarditis. A repeat CT showed the masses to be decreased in size and the patient was discharged with Clindamycin 300mg TID for an additional month. His last CT continued to show evidence of improvement and he was clinically improved as well, so clindamycin was discontinued and he was discharged from the Infectious Disease clinic. This case illustrates that caution must be used in making a presumptive diagnosis of HCC in a cirrhotic with a new liver mass. Other diagnostic tools such as serum markers (AFP), blood cultures and further imaging should be considered when biopsy is not an option and clinical features suggest alternative diagnoses

Treatment with tocilizumab or corticosteroids for COVID-19 patients with hyperinflammatory state: a multicentre cohort study (SAM-COVID-19)

Objectives: The objective of this study was to estimate the association between tocilizumab or corticosteroids and the risk of intubation or death in patients with coronavirus disease 19 (COVID-19) with a hyperinflammatory state according to clinical and laboratory parameters. Methods: A cohort study was performed in 60 Spanish hospitals including 778 patients with COVID-19 and clinical and laboratory data indicative of a hyperinflammatory state. Treatment was mainly with tocilizumab, an intermediate-high dose of corticosteroids (IHDC), a pulse dose of corticosteroids (PDC), combination therapy, or no treatment. Primary outcome was intubation or death; follow-up was 21 days. Propensity score-adjusted estimations using Cox regression (logistic regression if needed) were calculated. Propensity scores were used as confounders, matching variables and for the inverse probability of treatment weights (IPTWs). Results: In all, 88, 117, 78 and 151 patients treated with tocilizumab, IHDC, PDC, and combination therapy, respectively, were compared with 344 untreated patients. The primary endpoint occurred in 10 (11.4%), 27 (23.1%), 12 (15.4%), 40 (25.6%) and 69 (21.1%), respectively. The IPTW-based hazard ratios (odds ratio for combination therapy) for the primary endpoint were 0.32 (95%CI 0.22-0.47; p < 0.001) for tocilizumab, 0.82 (0.71-1.30; p 0.82) for IHDC, 0.61 (0.43-0.86; p 0.006) for PDC, and 1.17 (0.86-1.58; p 0.30) for combination therapy. Other applications of the propensity score provided similar results, but were not significant for PDC. Tocilizumab was also associated with lower hazard of death alone in IPTW analysis (0.07; 0.02-0.17; p < 0.001). Conclusions: Tocilizumab might be useful in COVID-19 patients with a hyperinflammatory state and should be prioritized for randomized trials in this situatio

A922 Sequential measurement of 1 hour creatinine clearance (1-CRCL) in critically ill patients at risk of acute kidney injury (AKI)

Meeting abstrac

Latin-American guidelines for opioid use in chronic nononcologic pain

Aim: Latin-American experts in the use of opioids in patients with chronic nononcologic pain (CNOP) have updated existing recommendations to current Latin-American reality. Methods: Several key opinion leaders from Latin America participated in a face-to-face meeting in Guatemala (April 2015) to discuss the use of opioids in CNOP. Subgroups of experts worked on specific topics, reviewed the literature and shaped the final manuscript. Results: The expert panel developed guidelines taking into consideration the utility of both opioid and nonopioid analgesics and factors pertaining to their efficacy, safety, adherence, administration and risks for abuse/addiction. Conclusion: Latin-American guidelines for the use of opioids in CNOP should improve pain relief and patients' quality of life by increasing access to these effective agents