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Case report
Sinusoidal obstruction syndrome secondary the intake of Senecio brasiliensis: A case report
Samantha Thifani Alrutz Barcelosa,d,
Corresponding author
Samanthatifani@gmail.com

Corresponding author:
, Vincent Marin Dall’Oglioa, Alexandre de Araújoa, Carlos Thadeu Schmidt Cerskib,c,d, Mário Reis Álvares-da-Silvaa,c,d
a Hepatology Division, Hospital de Clinicas de Porto Alegre, Brazil
b Pathology Division, Hospital de Clinicas de Porto Alegre, Brazil
c School of Medicine, Universidade Federal do Rio Grande do Sul, Brazil
d Graduate Program in Gastroenterology and Hepatology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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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">Hepatic sinusoidal obstructive syndrome &#40;HSOS&#41;&#44; formerly known as veno-occlusive disease&#44; is a vascular disease characterized by edema&#44; necrosis and detachment of endothelial cells in small sinusoidal hepatic and interlobular veins&#44; with intrahepatic congestion&#44; which leads to portal hypertension and liver dysfunction <a class="elsevierStyleCrossRefs" href="#bib0170">&#91;1&#44;2&#93;</a>&#46; Because of its presentation&#44; it might be mistaken with decompensated cirrhosis or other forms of acute liver disease&#44; which might delay the diagnosis and thus the proper treatment <a class="elsevierStyleCrossRef" href="#bib0180">&#91;3&#93;</a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">HSOS causes varies between West and East &#8211; in the latter it is mainly associated with oral ingestion of plants containing pyrrolidine alkaloid &#40;PA&#41;&#44; such as <span class="elsevierStyleItalic">Senecio brasiliensis</span>&#44; while in the Western world it is mostly restricted to the hematopoietic cell transplantation &#40;HCT&#41; and myeloablative treatment setting <a class="elsevierStyleCrossRef" href="#bib0185">&#91;4&#93;</a>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">2</span><span class="elsevierStyleSectionTitle" id="sect0020">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">We present a case of a white woman&#44; 54 years old&#44; with previous history of depression&#44; who was admitted at a hinterland hospital with a report of asthenia and malaise four days before admission&#46; When she started with jaundice&#44; she sought medical help and was promptly hospitalized&#46; The patient denied other comorbidities or use of medications except the daily use of a homemade tea of <span class="elsevierStyleItalic">S&#46; brasiliensis</span>&#44; a native plant to fields of South America prescribed by a healer in the last 20 days as a menopause therapy&#46; Ten days after admission she was transferred to our hospital liver unit&#46; On admission&#44; she denied any history of liver disease&#44; alcohol use and had no liver disease stigmata&#44; as well as no signs of coagulopathy or encephalopathy&#46; Her physical examination showed signs of ascites and bilateral pleural effusion&#46; Tests for acute viral infections &#40;IgM for A and B hepatitis&#44; EBV&#44; HSV&#44; HIV and VZV&#41; were negative&#44; except for a weak positive IgM serology for cytomegalovirus &#40;CMV&#41;&#46; CMV IgG antibody affinity was high&#44; with a low CMV viral load&#44; findings interpreted as possible reactivation in a context of critical disease&#46; Autoantibodies&#44; iron and copper metabolism tests performed at admission were also negative&#46; Laboratory values from admission were&#58; aspartate aminotransferase 585&#44; alanine aminotransferase 264&#44; total bilirubin 5&#46;08&#44; alkaline phosphatase 293&#44; &#947;-glutamyl transferase 452&#44; prothrombin time 15&#46;7s &#40;reference 13s&#41;&#44; 175&#44;000 platelets and factor V of 65&#37;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Abdominal ultrasound showed a normal sized spleen&#44; liver with normal dimensions&#44; smooth contours&#44; discrete heterogeneous echogenicity&#44; periportal edema&#44; portosystemic collateral venous circulation&#44; moderate amount of ascitic fluid and no signs of thrombosis of the hepatic venous portal system and tributaries&#46; Afterwards&#44; thorax and abdominal computed tomography &#40;CT&#41; revealed moderate bilateral pleural effusion&#44; with no signs of parenchymal disease&#44; while liver showed irregular surface&#44; fissures enlargement&#44; heterogeneity&#44; with portosystemic circulation and paraumbilical vein recanalization&#44; perigastric and periesophageal varices&#46; Portal vein diameter was 1&#46;5<span class="elsevierStyleHsp" style=""></span>cm &#40;normal 1&#46;2<span class="elsevierStyleHsp" style=""></span>cm&#41; and there was a voluminous ascites&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Calculated RUCAM score &#40;Roussel Uclaf Causality Assessment Method&#41;&#44; a tool used for quantitatively assess causality in cases of suspected drug or herbal liver injury <a class="elsevierStyleCrossRef" href="#bib0190">&#91;5&#93;</a>&#44; was 6&#44; compatible with probable injury related to the herbal &#40;2 points for time to onset &#8211; between 5 and 90 days&#44; 2 points on course of ALP after drug cessation &#8211; 452 initially&#44; 185 twenty days later&#44; 2 points for reaction labeled in the product characteristics&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Ascites and pleural effusion were sent to analysis on the first day&#44; and were compatible with transudate&#44; with a high serum-ascites albumin gradient &#40;SAAG&#41; &#8211; 1&#46;7&#46; Neutrophil count was higher than 250&#44; and patient was treated as having spontaneous bacterial peritonitis&#44; although there was no clear evidence of cirrhosis&#46; Eleven days after admission&#44; she developed a septic shock&#44; evolving with acute respiratory distress syndrome&#44; requiring mechanic ventilation&#46; Her clinical picture improved partially&#44; with extubation&#44; but worsening of mental status &#40;grade II encephalopathy&#41; and persistent renal disfunction&#44; progressing into oliguria and hydroelectrolytic dysbalance&#44; demanding hemodialysis fourteen days after admission&#46; The laboratory curves are shown in <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Considering the severity involving the scenario&#44; in spite of removing the causal factor&#44; and having uncertainty about the diagnosis&#44; the patient was submitted to a liver biopsy&#44; which showed a histologic pattern compatible with veno-occlusive disease &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Before starting anticoagulation&#44; in twenty-four days of hospitalization&#44; her clinical state suddenly got worse&#44; showing signs of shock&#44; abdominal distention and pain&#44; along with fecaloid vomit&#46; Urgent CT showed signs of mesenteric ischemia&#44; confirmed by exploratory laparotomy&#44; with resection of an 80<span class="elsevierStyleHsp" style=""></span>cm necrotic small bowel area&#46; Shortly afterwards&#44; despite support&#44; patient evolved to multiple organ dysfunction and death&#44; on the twenty-fifth day of admission&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">3</span><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">HSOS has two major causes&#58; cytotoxic or immunosuppressive agents&#44; such as cyclophosphamide&#44; and the ingestion of pyrrolidine agents&#44; such as <span class="elsevierStyleItalic">S&#46; brasiliensis</span>&#46; The syndrome should be suspected in patients with significant portal hypertension in the absence of cirrhosis&#46; Differential diagnosis include Budd-Chiari syndrome&#44; hepatic injury induced by another drugs&#44; acute alcoholic hepatitis&#44; and&#44; in selected cases&#44; decompensated cirrhosis <a class="elsevierStyleCrossRef" href="#bib0195">&#91;6&#93;</a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The main clinical symptoms of patients with PA-HSOS is highly similar to those with HCT-HSOS <a class="elsevierStyleCrossRef" href="#bib0200">&#91;7&#93;</a>&#46; The diagnosis of PA-HSOS is based on the patient&#39;s history of illness&#44; clinical manifestations&#44; imaging results and pathological features&#46; To facilitate the diagnosis of HCT-HSOS&#44; two different sets of clinical criteria have been described&#58; the revised Seattle and the Baltimore criteria&#46; These are based on the presence of clinical findings &#40;jaundice&#44; weight gain&#44; hepatomegaly and ascites&#41; not attributable to any other possible cause&#44; in the first 3 weeks after HCT <a class="elsevierStyleCrossRef" href="#bib0205">&#91;8&#93;</a>&#46; The treatment of PA-HSOS is mainly based on anticoagulation and antithrombotic agents in addition to supportive and liver protective treatments&#46; Although regular heparin or low molecular weight heparin has a strong anticoagulant effect in thrombotic diseases&#44; it has no significant preventive or therapeutic effect in patients with HCT and it increases the risk of bleeding <a class="elsevierStyleCrossRef" href="#bib0200">&#91;7&#93;</a>&#46; As a result&#44; regular heparin or low molecular weight heparin is not recommended for the treatment of HCT-HSOS <a class="elsevierStyleCrossRef" href="#bib0210">&#91;9&#93;</a>&#46; The efficacy of Transjugular Intrahepatic Portosystemic Shunt &#40;TIPS&#41; for PA-HCT is controversial&#46; Patients with HCT usually have serious underlying diseases that can affect the efficacy of TIPS <a class="elsevierStyleCrossRef" href="#bib0200">&#91;7&#93;</a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Pyrrolizidine alkaloids are a group of naturally occurring alkaloids based on the structure of pyrrolizidine&#46; The precise mechanism of hepatic injury is unknown but appears to result from accumulation of highly reactive electrophilic metabolites produced via P450 cytochrome enzyme system&#46; The increased concentration of P450 enzymes within the hepatic centrilobular region correlates with the changes seen histologically <a class="elsevierStyleCrossRef" href="#bib0215">&#91;10&#93;</a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Liver is the main target of pyrrolidine&#39;s alkaloids&#44; modifying sodium-potassium pump on liver&#39;s membrane&#44; causing endothelial edema on the hepatic vein&#44; stenosis of the centric hepatic venous lumen&#44; zone III necrosis and congestion of the hepatic sinusoids <a class="elsevierStyleCrossRefs" href="#bib0220">&#91;11&#44;12&#93;</a>&#46; Mortality rate varies according cause&#44; severity&#44; disease&#39;s evolution and therapy instituted&#44; but normally exceeds 40&#37; <a class="elsevierStyleCrossRefs" href="#bib0230">&#91;13&#44;14&#93;</a>&#46; The main clinical features are abdominal distention&#44; right hypochondrium pain&#44; anorexia&#44; malaise&#44; ascites&#44; jaundice and hepatomegaly <a class="elsevierStyleCrossRef" href="#bib0240">&#91;15&#93;</a>&#46; Most patients presents with symptoms within one month after the ingestion&#46; A significant portion of patients with severe disease or without response to the treatment have progressive exacerbations&#44; complicated by infection &#8211; mostly respiratory &#8211; and acute hepatic or renal failure&#44; as our patient had <a class="elsevierStyleCrossRef" href="#bib0245">&#91;16&#93;</a>&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">HSOS may be accompanied by progressive thrombocytopenia&#46; The main hepatic manifestations are elevation of bilirubin&#44; cholestasis markers and aminotransaminases&#46; Prothrombin time is generally normal or slightly prolonged&#46; Ascites usually had portal hypertension characteristics&#44; with a SAAG above 1&#46;1<span class="elsevierStyleHsp" style=""></span>g&#47;L <a class="elsevierStyleCrossRef" href="#bib0250">&#91;17&#93;</a>&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Ultrasonography have a diagnosis value&#44; depending on the expertise of the physician&#46; Typical findings include hepatomegaly&#44; splenomegaly&#44; ascites&#44; thickening of gallbladder&#39;s walls&#44; dilated portal vein &#40;&#62;12<span class="elsevierStyleHsp" style=""></span>mm diameter&#41; and narrowing of the hepatic veins <a class="elsevierStyleCrossRef" href="#bib0255">&#91;18&#93;</a>&#46; Abdominal CT often shows hepatomegaly&#44; low density and heterogeneity of hepatic parenchyma <a class="elsevierStyleCrossRef" href="#bib0260">&#91;19&#93;</a>&#46; Hypodensity hepatic areas&#44; within the venous phase&#44; correlate to blood stasis inside the hepatic sinusoids <a class="elsevierStyleCrossRefs" href="#bib0265">&#91;20&#44;21&#93;</a>&#46; Magnetic resonance&#39;s findings are similar <a class="elsevierStyleCrossRefs" href="#bib0275">&#91;22&#44;23&#93;</a>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">HSOS differs from most other liver diseases in which circulatory changes are the cause rather than the consequence of the liver injury&#46; Impairment of circulation leads to hepatocyte necrosis and eventual liver failure&#46; Although early studies and the original name of the disease &#40;hepatic veno-occlusive disease&#41; suggest that SOS originates in the hepatic veins&#44; analysis of clinical material demonstrated that the critical change is obstruction at the sinusoids with increased frequency of involvement of the central veins in more severe cases <a class="elsevierStyleCrossRefs" href="#bib0275">&#91;22&#44;23&#93;</a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Liver biopsy is an option to confirm the diagnosis in suspected patients&#44; mainly those with abnormal and atypical laboratory&#47;imaging findings&#44; and shows significant dilation and congestion of zone III&#39;s hepatic sinusoids&#44; various degrees of edema and necrosis of hepatocytes&#44; interlobular veins&#8217; endothelial cells injury and edema&#46; The first pathological changes involve damage to the microscopic anatomy of hepatic sinusoid endothelial cells&#44; followed by the development of hepatic sinusoid obstruction&#44; endothelial cell damage&#44; and impaired integrity of sinusoid walls&#44; with hepatic sinusoid congestion&#46; Pathological manifestations in the acute phase include hepatocellular necrosis&#44; endothelial swelling of the hepatic vein&#44; thickening of the hepatic vein walls&#44; and significant expansion and congestion of the sinuses&#46; The pathological manifestations among patients in the subacute and chronic phases included central lobular fibrosis and non-portal liver cirrhosis&#44; the latter particularly in the chronic phase <a class="elsevierStyleCrossRefs" href="#bib0260">&#91;19&#44;24&#44;25&#93;</a>&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The main treatment consists of suspending the agent causing the syndrome&#46; As with cirrhosis&#44; spironolactone and furosemide are good options for treatment of ascites and pleural effusions&#44; reserving TIPS to refractory ascites <a class="elsevierStyleCrossRefs" href="#bib0200">&#91;7&#44;26&#93;</a>&#46; Hemodialysis should be an option in case of systemic congestion or acute renal failure&#46; The effectiveness of glucocorticoids is controversial&#46; Pulse therapy can be done&#44; but the risk of infection should be considered&#44; and the degree of evidence is low <a class="elsevierStyleCrossRef" href="#bib0300">&#91;27&#93;</a>&#46; Anticoagulant treatment is recommended to be started as soon as possible in cases of acute&#47;subacute presentation&#46; Contraindications include active hemorrhage or tendency to bleeding&#46; Low molecular weight heparin is the first choice&#44; followed by vitamin K antagonists&#44; such as warfarin&#46; The recommended dosage for enoxaparin is 1<span class="elsevierStyleHsp" style=""></span>mg BID&#44; subcutaneously&#44; and the majority of patients do not need monitoring&#46; Careful or avoiding should be warranted in chronic renal failure patients&#46; Warfarin is the long term preferred drug&#44; with a target International Normalized Ratio between 2 and 3&#44; for at least 3 months <a class="elsevierStyleCrossRefs" href="#bib0305">&#91;28&#44;29&#93;</a>&#46; Liver transplantation should be considered to patients with acute liver failure who fail to respond to the clinical treatment <a class="elsevierStyleCrossRef" href="#bib0315">&#91;30&#93;</a>&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Defibrotide&#44; a complex of single-stranded oligodeoxyribonucleotides derived from porcine or bovine mucosal DNA&#44; is the only effective drug indicated specific to HSOS treatment&#44; but it&#39;s not widely available <a class="elsevierStyleCrossRef" href="#bib0320">&#91;31&#93;</a>&#46; The mechanism of action is attributed to the protective anti-inflammatory and anti-thrombotic actions on endothelial cells <a class="elsevierStyleCrossRef" href="#bib0320">&#91;31&#93;</a>&#46; A recent systematic analysis showed a 100-day survival of 41&#8211;70&#37; <a class="elsevierStyleCrossRef" href="#bib0325">&#91;32&#93;</a>&#46; The high cost of defibrotide&#44; however&#44; is an impediment for its use&#46; This drug is not supplied in our healthy system&#59; therefore&#44; it is difficult to use it promptly&#46; Besides that&#44; the published studies and recommendations indicates that defibrotide is an effective therapy for the treatment of HSOS following haemopoietic stem cell transplantation <a class="elsevierStyleCrossRefs" href="#bib0205">&#91;8&#44;33&#93;</a>&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">4</span><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="par0090" class="elsevierStylePara elsevierViewall">HSOS is a high mortality syndrome&#46; This report highlights the importance of considering this condition as a differential diagnosis in patients with portal hypertension&#44; and also the potential toxic effect concerning use of medicinal plants&#46;<span class="elsevierStyleDefList"><span class="elsevierStyleSectionTitle" id="sect0035">Abbreviations</span><span class="elsevierStyleDefTerm">HSOS</span><span class="elsevierStyleDefDescription"><p id="par0095" class="elsevierStylePara elsevierViewall">sinusoidal obstruction syndrome</p></span><span class="elsevierStyleDefTerm">PA</span><span class="elsevierStyleDefDescription"><p id="par0100" class="elsevierStylePara elsevierViewall">pyrrolidine alkaloid</p></span><span class="elsevierStyleDefTerm">HCT</span><span class="elsevierStyleDefDescription"><p id="par0105" class="elsevierStylePara elsevierViewall">hematopoietic cell transplantation</p></span><span class="elsevierStyleDefTerm">CMV</span><span class="elsevierStyleDefDescription"><p id="par0110" class="elsevierStylePara elsevierViewall">cytomegalovirus</p></span><span class="elsevierStyleDefTerm">CT</span><span class="elsevierStyleDefDescription"><p id="par0115" class="elsevierStylePara elsevierViewall">computed tomography</p></span><span class="elsevierStyleDefTerm">SAAG</span><span class="elsevierStyleDefDescription"><p id="par0120" class="elsevierStylePara elsevierViewall">serum-ascites albumin gradient</p></span><span class="elsevierStyleDefTerm">TIPS</span><span class="elsevierStyleDefDescription"><p id="par0125" class="elsevierStylePara elsevierViewall">Transjugular Intrahepatic Portosystemic Shunt</p></span></span></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Funding source</span><p id="par0130" class="elsevierStylePara elsevierViewall">There has been no financial support for this work&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hepatic sinusoidal obstruction syndrome &#40;HSOS&#41; is a hepatic vascular disease histologically characterized by edema&#44; necrosis&#44; detachment of endothelial cells in small sinusoidal hepatic and interlobular veins and intrahepatic congestion&#44; which leads to portal hypertension and liver dysfunction&#46; In the Western world&#44; most HSOS cases are associated with myeloablative pretreatment in a hematopoietic stem cell transplantation setting&#46; Here we report a case of a 54 years old female patient&#44; otherwise healthy&#44; with no history of alcoholic ingestion&#44; who presented with jaundice and signs of portal hypertension&#44; including ascites and bilateral pleural effusion&#46; She had no history of liver disease and denied any other risk factor for liver injury&#44; except <span class="elsevierStyleItalic">Senecio brasiliensis</span> ingestion as a tea&#44; prescribed as a therapy for menopause&#46; Acute viral hepatitis and thrombosis of the portal system were excluded in complementary investigation&#44; as well as sepsis&#44; metastatic malignancy and other liver diseases&#44; setting a RUCAM score of 6&#46; Computed tomography demonstrated a diffuse liver parenchymal heterogeneity &#40;in mosaic&#41; and an extensive portosystemic collateral venous circulation&#44; in the absence of any noticeable venous obstruction&#46; HSOS diagnosis was confirmed through a liver biopsy&#46; During the following-up period&#44; patient developed refractory pleural effusion&#44; requiring hemodialysis&#46; Right before starting anticoagulation&#44; she presented with abdominal pain and distention&#44; with findings compatible of mesenteric ischemia by computed tomography&#46; A laparotomy was performed&#44; showing an 80<span class="elsevierStyleHsp" style=""></span>cm segment of small bowel ischemia&#44; and resection was done&#46; She died one day after as a result from a septic shock refractory to treatment&#46; The presented case was related to oral intake of <span class="elsevierStyleItalic">S&#46; brasiliensis</span>&#44; a plant containing pyrrolidine alkaloids&#44; which are one of the main causes of HSOS in the East&#44; highlighting the risk of liver injury with herbs intake&#46;</p></span>"
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Article information
ISSN: 16652681
Original language: English
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es en pt

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