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INTRODUCTION: Hydroxychloroquine is a commonly prescribed medication with antimalarial and anti-inflammatory properties. A very rarely reported side effect of this medication is drug induced acute liver injury. CASE DESCRIPTION/METHODS: A 62-year old female with a history of rheumatoid arthritis, on long term prednisone, presented to the emergency department with two day history of arthralgias, generalized weakness, and fever of 104 F. She had no history of alcohol use or any risk factors for viral hepatitis. Clinical exam was unremarkable. Laboratory data showed Aspartate aminotransferase (AST) or 798 IU/L and Alanine aminotransferase (ALT) of 1254 IU/L, with normal serum bilirubin, alkaline phosphatase and coagulation profile. Serologic tests for viral etiology including Hepatitis A, Hepatitis B, Hepatitis C, Cytomegalovirus, Epstein-Barr virus, and Human immunodeficiency virus were non-reactive. Anti-nuclear antibody, smooth muscle antibody, and anti-double-stranded DNA antibody were unremarkable. Her urine and blood cultures showed no growth. Abdominal ultrasound showed an echogenic liver consistent with hepatic steatosis and no evidence of biliary obstruction. Chest X-ray was normal. Upon review of her medications, patient had started hydroxychloroquine two weeks prior to admission. The medication was discontinued upon admission, after which she continued to improve. At follow up ten days later, she remained asymptomatic and her liver function tests continued to improve with AST of 46 and ALT of 161. DISCUSSION: Acute transaminitis due to hydroxychloroquine is rare. Only four reported cases have been noted per literature review. Mechanism of injury to hepatic cells is unknown however the drug is metabolized in the liver and may alter the metabolism of other drugs. Porphyria cutanea tarda is a disease that may be treated with low doses of hydroxychloroquine. It is known that higher doses of hydroxychloroquine usually greater than 100 mg twice a week can trigger acute liver injury in patients with history of Porphyria cutana tarda. These patients present with sudden onset of fever and marked serum enzyme elevations with increased excretion of porphyrins and photosensitivity. The presented patient in the case report did not have underlying Porphyria cutanea tarda.

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Introduction:The COVID-19 pandemic has caused millions of deaths and infections worldwide. Patients with multiple medical comorbidities are more vulnerable. Veterans have more health conditions than the general population with higher prevalence of HTN, DM, and lung disease. Veterans with IBD are predisposed to COVID-19 and have higher rates of associated hospitalizations and mortality. COVID-19 vaccination rates in IBD patients in community settings is 41%, lower than the general population and WHO recommendations. The 2020 veteran mortality rate rose to an all-time high, with a 13% increase or 50,299 excess deaths). We examined the rates of and barriers to COVID-19 vaccination in the veteran population with IBD. Methods: We conducted a retrospective cross-sectional study at a VAMC. Data for demographics, subtype of IBD (i.e., ulcerative colitis or Crohn's disease), and biologic therapy were collected. Unvaccinated veterans completed a 15-item survey of 4 structural barriers and 11 attitudinal barriers to vaccination via a phone call. Results: We identified 206 veterans with IBD, 34 (16.5%) of whom were not vaccinated. Mean age for the vaccinated was 66 years and for the unvaccinated 54 years (p, 0.001). The two groups did not differ on sex (male 95% and 91%), race (Caucasian 86% and 87%), type of IBD (UC 63% and 55%), and biologic therapy (37% and 35%). The leading structural barrier was primary care provider or GI physician did not provide enough information about the vaccine(41%). The leading attitudinal barriers were (1) not agree that the government mandates were appropriate (91%) and ( 2) afraid of vaccinations (62%). Conclusion: The 83.5% COVID-19 vaccination rate for IBD patients was higher than the general population rate of 66%.1 Lack of provider counseling, disagree with government mandates, and fear of vaccines were major barriers. Due to their comorbidities and immunologic suppression from treatment, gastroenterologists managing IBD patients should discuss COVID-19 immunization including the importance of being immunized, fear of vaccines, and possible side effects. Vaccine hesitancy must be targeted locally and nationally, with compassion and empathy. Our findings can be applied to future pandemics and global health policies and be the basis for studies of psychosocial components that impact veterans' compliance with vaccinations.

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