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Case report
Acute liver injury, acute liver failure and acute on chronic liver failure: A clinical spectrum of poisoning due to Gyromitra esculenta
Magdalena Arłukowicz-Grabowskaa,
Corresponding author
arlukowicz.m@gmail.com

Corresponding author at: Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, ul. Banacha 1a, 02-097 Warsaw, Poland.
, Maciej Wójcickia, Joanna Raszeja-Wyszomirskaa, Monika Szydłowska-Jakimiuka, Bernard Piotuchb, Piotr Milkiewicza,c
a Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Poland
b Department of Surgery, Ministry of the Interior and Administration Hospital, Szczecin, Poland
c Translation Medicine Group, Pomeranian Medical University, Szczecin, Poland
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;a&#41; <span class="elsevierStyleItalic">Gyromitra esculenta</span>&#44; &#8220;false morel&#8221;&#46; &#40;b&#41; <span class="elsevierStyleItalic">Morchella esculenta</span>&#44; &#8220;true morel&#8221;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">1</span><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Among thousands of mushroom species that are found all over the world&#44; approximately one hundred are poisonous to humans&#46; Most of them cause mild symptoms&#44; such as gastrointestinal disturbances like nausea&#44; vomiting&#44; diarrhea&#44; or other manifestations like fever&#44; muscle pain and a headache&#46; Poisonous mushroom ingestion could also result in severe&#44; life-threatening toxicity <a class="elsevierStyleCrossRef" href="#bib0100">&#91;1&#93;</a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Acute liver failure &#40;ALF&#41; manifests with abnormal liver functions with impaired coagulation &#40;INR &#62;1&#46;5&#41; and signs of encephalopathy&#44; and manifestations of the latter could be up to 24 weeks from onset of illness in a patient with no previous history of liver disease&#46; Whereas the term of acute liver injury &#40;ALI&#41; refers to patients with coagulopathy and no signs of encephalopathy <a class="elsevierStyleCrossRefs" href="#bib0105">&#91;2&#44;3&#93;</a>&#46; Its occurrence following <span class="elsevierStyleItalic">Amanita phalloides</span> mushroom poisoning is well known with the associated morbidity&#44; mortality and often the need for liver transplantation in a significant proportion of cases&#46; However&#44; ALF due to <span class="elsevierStyleItalic">Gyromitra esculenta</span> mushrooms ingestion is less well reported&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">G&#46; esculenta</span>&#44; also known as a &#8220;false morel&#8221; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#41;&#44; is well documented as one of the most poisonous mushrooms&#46; This species grow all over the world mostly in coniferous forests in early spring time&#46; The mushroom is of medium size &#40;5 up to 16<span class="elsevierStyleHsp" style=""></span>cm&#41; with a typical irregular &#8216;brain-shaped&#8217; cap &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#41;&#46; Unfortunately&#44; &#8220;false morel&#8221; is easily confused with <span class="elsevierStyleItalic">Morchella esculenta</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>b&#41;&#44; which is known as a &#8220;true morel&#8221; and an exclusive culinary product <a class="elsevierStyleCrossRef" href="#bib0115">&#91;4&#93;</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Herein&#44; we describe a case of acute liver injury&#44; a case of ALF and an additional case of acute-on-chronic liver failure &#40;ACLF&#41; due to <span class="elsevierStyleItalic">G&#46; esculenta</span> poisoning&#46; Two patients recovered following typical medical treatment while a patient with acute-on-chronic liver failure died&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">2</span><span class="elsevierStyleSectionTitle" id="sect0020">Case 1 &#8211; acute liver injury</span><p id="par0025" class="elsevierStylePara elsevierViewall">A 61-year-old male patient was admitted to our unit in April 2014&#44; two days after eating &#8220;brain-like&#8221; mushrooms&#46; The patient experienced abdominal pain two days after the mushroom ingestion and this was associated with vomiting&#44; intense watery diarrhea&#44; and on admission was jaundiced&#46; There were no signs of encephalopathy&#46; Laboratory tests confirmed ALI &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Abdominal ultrasound showed signs of minor liver enlargement&#46; Following supportive medical treatment the liver functions improved&#46; The patient was discharged home 9 days after admission&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">3</span><span class="elsevierStyleSectionTitle" id="sect0025">Case 2 &#8211; acute liver failure</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 67-year-old male patient was admitted to our Unit in April 2016 with signs of abdominal pain&#44; fever&#44; headache and jaundice that were followed by altered mentation&#46; This occurred three days after ingestion of mushrooms&#44; which the patient described as being very similar to &#8220;true morels&#8221;&#46; The patient was irritable&#44; mildly confused and found to be jaundiced with a tender right upper quadrant of abdomen&#46; Laboratory blood tests confirmed acute liver failure &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; and the patient had signs of encephalopathy grade 3 according to West Haven Criteria <a class="elsevierStyleCrossRef" href="#bib0120">&#91;5&#93;</a>&#46; The patient continued to deteriorate despite supportive care and required listing for a liver transplantation&#46; The decision for liver transplantation was based primarily on rapidity and severity of deterioration even though the patient did not fulfill all of the Kings College criteria <a class="elsevierStyleCrossRef" href="#bib0125">&#91;6&#93;</a> for listing in fulminant hepatic failure&#46; The clinical picture however stabilized and there was improvement noted in the 48<span class="elsevierStyleHsp" style=""></span>h that followed resulting in the patient being taken off the waiting list for a transplant&#46; After eleven days of continued medical treatment&#44; the patient improved to be discharged home with liver function tests normalized&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4</span><span class="elsevierStyleSectionTitle" id="sect0030">Case 3 &#8211; acute-on-chronic liver failure</span><p id="par0035" class="elsevierStylePara elsevierViewall">A 59-year-old man with a history of HCV hepatitis &#40;untreated&#44; diagnosed in 2002&#41; and diabetes presented in April 2016&#44; three days after eating mushrooms&#44; which his family described as a &#8220;false morel&#8221;&#46; A few hours after ingestion symptoms including muscle pain with vomiting and diarrhea were observed&#46; At admission he had grade 3 encephalopathy&#46; The patient rapidly developed multi-organ failure requiring inotrope support&#44; invasive ventilator support and hemodialysis &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; He also required glucose infusion to maintain normoglycemia&#46; He received a standard treatment with intravenous colloids&#44; crystalloids and glucose&#46; His encephalopathy was treated with intravenous <span class="elsevierStyleSmallCaps">l</span>-ornithine <span class="elsevierStyleSmallCaps">l</span>-aspartate&#46; The abdominal ultrasound revealed enlarged and heterogenous liver parenchyma with no signs of portal hypertension and normal spleen&#46; The patient did not however fulfill the Kings College criteria <a class="elsevierStyleCrossRef" href="#bib0125">&#91;6&#93;</a>&#46; Despite signs of continued deterioration of liver function the option of liver transplantation was not considered feasible due to established multi-organ failure&#46; The patient died 5 days following mushroom ingestion&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">5</span><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">There are various types of wild mushrooms growing in forests&#44; which are often eaten by foragers&#46; Only about 2&#37; &#40;out of more than 5000 species that are found worldwide&#41; are poisonous&#46; This includes <span class="elsevierStyleItalic">G&#46; esculenta</span>&#44; so called &#8220;false morel&#8221; <a class="elsevierStyleCrossRef" href="#bib0130">&#91;7&#93;</a>&#46; Herein&#44; we describe the clinical course of three patients to emphasize variable symptoms of poisoning&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The poisoning with <span class="elsevierStyleItalic">G&#46; esculenta</span> should be considered and differentiated from other causes of toxic liver failure which occur in the spring time&#44; as opposed to <span class="elsevierStyleItalic">A&#46; phalloides</span> occurring in autumn&#46; It is also not typically shaped with a stem and a cap <a class="elsevierStyleCrossRefs" href="#bib0135">&#91;8&#44;9&#93;</a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The manifestations of poisoning following ingestion of <span class="elsevierStyleItalic">G&#46; esculenta</span> usually occur around 12<span class="elsevierStyleHsp" style=""></span>h following ingestion with gastrointestinal symptoms followed by jaundice within 2&#8211;3 days and significant increase of AST&#44; ALT and INR with a degree of encephalopathy&#46; There is a paucity of reported publications of poisoning following ingestion of <span class="elsevierStyleItalic">G&#46; esculenta</span>&#44; limited to a few case reports <a class="elsevierStyleCrossRefs" href="#bib0145">&#91;10&#44;11&#93;</a>&#46; In these too most patients described failed to fulfill criteria for ALF or even ALI&#44; with moderate transaminitis being the main feature&#46; However&#44; fatal cases have also been reported <a class="elsevierStyleCrossRef" href="#bib0155">&#91;12&#93;</a>&#46; The toxin gyromytrin&#44; chemically identified as an N-methyl-N-formylhydrazone is a water soluble compound that evaporates easily at normal temperatures <a class="elsevierStyleCrossRef" href="#bib0160">&#91;13&#93;</a>&#46; The toxin could be therefore partially deactivated or even eliminated by cooking or drying&#46; However partial cooking could lead to hydrolyzation which could also be caused by the acidity of the stomach following ingestion&#44; to the direct toxin-monomethylhydrazine &#40;MMH&#41;&#46; Metabolic intermediates of gyromytrin toxin-free methyl radical and an unstable diazonium compound&#44; which arises after oxidation from MMH damage hepatocytes&#44; causing their necrosis and interfere with cytochrome enzymes &#40;mainly P450&#41;&#44; aminooxidases and glutathione pathways <a class="elsevierStyleCrossRef" href="#bib0165">&#91;14&#93;</a>&#46; This may be combined with a degree of neurotoxicity by modulating pyridoxine dependent coenzymes&#44; therefore having influence on gamma-aminobutyric acid &#40;GABA&#41; levels <a class="elsevierStyleCrossRef" href="#bib0170">&#91;15&#93;</a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The three patients described developed liver disfunction of varied severity following <span class="elsevierStyleItalic">G&#46; esculenta</span> poisoning&#46; Our report highlights the possibility <span class="elsevierStyleItalic">G&#46; esculenta</span> ingestion may cause an acute liver failure&#46; It is likely that in subjects with underlying or preexistent liver dysfunction the course may be very aggressive with death a likely outcome&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Described cases show limited utility of widely used criteria selecting patient with urgent need of transplantation <a class="elsevierStyleCrossRef" href="#bib0125">&#91;6&#93;</a>&#46; This reinforces the need to develop new prognostic or diagnostic tests of high sensitivity and specificity that would allow adequate placing patients on high urgency waiting list for liver transplantation&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The clinical indications for emergency liver transplantation are commonly based on the King&#39;s College Hospital Criteria or Clichy criteria <a class="elsevierStyleCrossRef" href="#bib0125">&#91;6&#93;</a>&#46; However&#44; their sensitivity and specificity in patients with ALF due to some rare causes are not clearly specified&#46; The utility of Kings College criteria has previously been evaluated in case of <span class="elsevierStyleItalic">A&#46; phalloides</span> poisoning&#46; Interestingly&#44; the sensitivity of only 25&#37; with 80&#37; specificity of predicting poor outcome in case of amatoxin induced ALF have been reported <a class="elsevierStyleCrossRef" href="#bib0175">&#91;16&#93;</a>&#46; This contradicts with a series reported by Escudie et al&#46; <a class="elsevierStyleCrossRef" href="#bib0180">&#91;17&#93;</a> who reported Kings College sensitivity and specificity of 100&#37; each in case of <span class="elsevierStyleItalic">A&#46; phalloides</span> poisoning&#46; According to Ganzert et al&#46; <a class="elsevierStyleCrossRef" href="#bib0185">&#91;18&#93;</a>&#44; the combination of serum creatinine above 106<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;L and PT index less than 25&#37; strongly suggests the urgent need for liver transplantation <a class="elsevierStyleCrossRef" href="#bib0185">&#91;18&#93;</a>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Some parameters may also be helpful in predicting prognosis&#44; among them proven factors of poor outcome are&#58; encephalopathy and kidney impairment <a class="elsevierStyleCrossRef" href="#bib0180">&#91;17&#93;</a>&#44; lactic acidosis&#44; especially when observed with coexisting hepatic encephalopathy <a class="elsevierStyleCrossRef" href="#bib0190">&#91;19&#93;</a>&#44; time interval shorter than 8<span class="elsevierStyleHsp" style=""></span>h between eating mushrooms and the occurrence of first symptoms &#40;such as vomiting or diarrhea <a class="elsevierStyleCrossRef" href="#bib0175">&#91;16&#93;</a>&#46; Nevertheless&#44; majority of prognostic factors following mushroom intoxication refer to <span class="elsevierStyleItalic">A&#46; phalloides</span> poisoning&#46; In comparison however there is less known about <span class="elsevierStyleItalic">G&#46; esculenta</span> poisoning to help with prognostication&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In summary&#44; <span class="elsevierStyleItalic">G&#46; esculenta</span> poisoning represents a rare but potentially dangerous clinical scenario that should always be considered in the spring time in regions it is found&#46; Given the limited sensitivity and specificity of currently available prognostic criteria&#44; such patients should preferably be transferred to liver transplant and hepatology units early&#46; Efforts should be made to develop more precise and sensitive prognostic criteria that could help clinicians in selecting the patients for liver transplantation&#46;<span class="elsevierStyleDefList"><span class="elsevierStyleSectionTitle" id="sect0040">Abbreviations</span><span class="elsevierStyleDefTerm">ACLF</span><span class="elsevierStyleDefDescription"><p id="par0080" class="elsevierStylePara elsevierViewall">acute-on-chronic liver failure</p></span><span class="elsevierStyleDefTerm">ALF</span><span class="elsevierStyleDefDescription"><p id="par0085" class="elsevierStylePara elsevierViewall">acute liver failure</p></span><span class="elsevierStyleDefTerm">ALI</span><span class="elsevierStyleDefDescription"><p id="par0090" class="elsevierStylePara elsevierViewall">acute liver failure</p></span><span class="elsevierStyleDefTerm">INR</span><span class="elsevierStyleDefDescription"><p id="par0095" class="elsevierStylePara elsevierViewall">international normalized ratio</p></span><span class="elsevierStyleDefTerm">GABA</span><span class="elsevierStyleDefDescription"><p id="par0100" class="elsevierStylePara elsevierViewall">gamma-aminobutyric acid</p></span><span class="elsevierStyleDefTerm">MMH</span><span class="elsevierStyleDefDescription"><p id="par0105" class="elsevierStylePara elsevierViewall">monomethylhydrazine</p></span></span></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">Nothing to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:9 [
        0 => array:3 [
          "identificador" => "xres1199047"
          "titulo" => "Abstract"
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              "identificador" => "abst0005"
            ]
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        1 => array:2 [
          "identificador" => "xpalclavsec1117487"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        3 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Case 1 &#8211; acute liver injury"
        ]
        4 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Case 2 &#8211; acute liver failure"
        ]
        5 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Case 3 &#8211; acute-on-chronic liver failure"
        ]
        6 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Discussion"
        ]
        7 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Conflict of interest"
        ]
        8 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2018-07-28"
    "fechaAceptado" => "2018-11-28"
    "PalabrasClave" => array:1 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1117487"
          "palabras" => array:3 [
            0 => "Acute liver failure"
            1 => "Mushroom poisoning"
            2 => "<span class="elsevierStyleItalic">Gyromitra esculenta</span>"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:1 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Gyromitra esculenta</span>&#44; also known as &#8220;false morel&#8221; is one of the most poisonous mushrooms&#46; This species is found all over the world&#44; growing in coniferous forest in early spring time&#46; Common manifestation of poisoning includes gastrointestinal symptoms which include varied degrees of liver impairment&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We describe three cases&#58; acute liver injury&#44; acute liver failure and acute-on-chronic liver failure due to <span class="elsevierStyleItalic">G&#46; esculenta</span> poisoning&#46; At admission patients presented with encephalopathy and features of liver failure&#46; Two of them recovered completely following supportive management while the remaining patient who also had preexisting liver disease developed multiorgan failure and subsequently died&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Although a rare occurrence&#44; <span class="elsevierStyleItalic">G&#46; esculenta</span> poisoning should be considered in the differential diagnosis of acute liver failure&#46;</p></span>"
      ]
    ]
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      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;a&#41; <span class="elsevierStyleItalic">Gyromitra esculenta</span>&#44; &#8220;false morel&#8221;&#46; &#40;b&#41; <span class="elsevierStyleItalic">Morchella esculenta</span>&#44; &#8220;true morel&#8221;&#46;</p>"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Normal ranges&#58; AST 5&#8211;40<span class="elsevierStyleHsp" style=""></span>U&#47;L&#59; ALT 7&#8211;56<span class="elsevierStyleHsp" style=""></span>U&#47;L&#59; INR 0&#46;9&#8211;1&#46;3&#59; total bilirubin 0&#46;2&#8211;1&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; serum creatinine 0&#46;6&#8211;1&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; encephalopathy grade West Heaven 0&#8211;4&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; ALT&#44; alanine transaminase&#59; AST&#44; aspartate aminotransferase&#59; S&#46;cr&#44; serum creatine&#59; INR&#44; international normalized ratio&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Gender&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AST IU&#47;L&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">ALT IU&#47;L&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">S&#46; cr mg&#47;dL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Bilirubin mg&#47;dL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">INR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Encephalopathy grade&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">Case 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1032&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2248&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;65&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Alive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2422&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2657&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;67&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;68&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Alive&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Case 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7605&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5183&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">10&#46;42&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A comparison of laboratory features at admission between three cases after <span class="elsevierStyleItalic">Gyromitra esculenta</span> poisoning&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
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            0 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "&#91;1&#93;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mushrooms"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "H&#46; Persson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Medicine"
                        "fecha" => "2016"
                        "volumen" => "44"
                        "paginaInicial" => "116"
                        "paginaFinal" => "119"
                      ]
                    ]
                  ]
                ]
              ]
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            1 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "&#91;2&#93;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "EASL Clinical Practical Guidelines on the management of acute &#40;fulminant&#41; liver failure"
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Article information
ISSN: 16652681
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos