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INTRODUCTION: Approximately 500,000 Clostridioides difficile infections (CDIs) occur annually in the USA. Recurrent CDI occurs in 20 to 30% patients with increasing rates of recurrence with each subsequent episode. Initial recurrences are treated with additional antibiotic regimens. Current treatment guidelines recommend fecal microbiota transplant (FMT) therapy after a 2nd recurrence treatment failure. Intravenous Immunoglobulin (IVIG) has been shown to be effective as a treatment adjunct in patients with CDI and hypogammaglobulinemia as well as in cases of severe and refractory CDI. Herein, we present a case of a patient with refractory CDI for two and a half years whose symptoms resolved after the addition of therapy with IVIG. CASE DESCRIPTION/METHODS: A 47 year old woman with refractory CDI for 2.5 years was admitted to our facility. She typically had 20 to 40 episodes of non-bloody diarrhea per day. Prior treatment courses included 4 fecal microbiota transplants, 13 oral vancomycin tapers, courses of metronidazole, 1 course of fidaxomicin, and colonic lavage with vancomycin installation, none of which provided relief for more than 1 week. Previously she had undergone EGD and colonoscopy with gastric, duodenal, colonic and terminal ileum biopsies which were unrevealing. Testing for celiac disease, TSH, ESR, CRP, gastrin level, Chromogranin A, vasoactive intestinal peptide 5-HIAA levels and stool osmolar gap were unremarkable. The patient had normal vital signs and had no major laboratory abnormalities. Total IgG was only slightly low at 667 mg/dL, normal range per hospital lab is 700-1600 mg/dL. Stool studies revealed persistent CDI. CT abdomen and pelvis w/o contrast showed no acute findings. She was started on Vancomycin 500 mg PO qid and diarrhea persisted. Colonoscopy with random biopsies revealed normal colonic mucosa and biopsies were negative. IVIG was added to enhance her immune response to refractory CDI. IVIG 20 g was administered daily for 2 days resulting in a dramatic decrease in diarrhea and the patient was discharged in good condition on hospital day 10. DISCUSSION: For our patient adjunctive treatment with IVIG led to resolution of infection and the avoidance of a total colectomy. We suggest consideration for incorporating IVIG therapy in difficult to manage CDI regardless of immunoglobulin status. A need remains for randomized control trials to better establish the optimal timing and dosing of IVIG in the treatment of CDI.

INTRODUCTION: Anabolic-androgenic steroid abuse has been steadily increasing in the general population. According to a 2014 study, approximately 1 in 50 students in the 12th grade reported using anabolic steroids. Trenbelone acetate is a synthetic anabolic androgen which is an agonist of the androgen receptor and most often used in cattle. CASE DESCRIPTION/METHODS: A 23 year old male with no significant past medical history presented with complaints of jaundice and generalized weakness which began 10 days prior to presentation. Patient endorsed weekly IM trenbelone 1000 mg weekly over the last 8 weeks. Physical examination was remarkable for icterus and appropriate mentation. Initial investigations reflected a total bilirubin of 13.44 mg/dL, AST 159 IU/L, ALT 425 IU/L, PT 11.0, INR 1.0, and Alk Phos of 142. Serologies were negative for viral hepatitis, anti-mitochondrial antibody, anti-smooth muscle antibody and ANA of 1:40. A liver ultrasound reported normal liver size without biliary obstruction. Patient's liver chemistries improved over the next three days and he was discharged with total bilirubin of 12.54 mg/dL, AST 135 IU/L, ALT 320 IU/L, PT 11.0, INR 1.0 and Alk Phos of 121. Patient advised to abstain from any future use of trenbelone. On repeat labs in 10 days, his total bilirubin of 29.50 mg/dL, AST 78, ALT 123, PT 20.1, INR 1.85 and Alk Phos 242. Physical examination noted worsening jaundice overall along with icterus but mentation remained appropriate. Patient denied any new medications and no further use of trenbelone since discharge. Patient's liver chemistries remained stable and he underwent MRI abdomen which was unremarkable. Patient was discharged home on ursodiol 300 mg BID. Patient's liver chemistry improved in one week and returned to baseline in one month. DISCUSSION: Anabolic steroids have been linked to four different forms of liver injury including an acute cholestatic syndrome such as in our patient, elevation in serum enzymes, chronic vascular injury and hepatic tumors including adenomas and hepatocellular carcinoma. Mechanism of cholestatic syndrome is not well defined in this type of injury. Urosdiol has been used in the past for treatment however efficacy has not been shown in a study. Healthcare provides managing patients with elevated liver chemistries should able to recognize anabolic induced liver injury given increasing use and ease of availability of such performance enhancing drugs.