§ Drs. Murphy and Parikh contributed equally and are co-senior authors Author contributions: Dr. Singal had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design (Singal and Parikh); Acquisition, analysis and interpretation of the data (all authors); Drafting of the manuscript (Singal); Critical revision of the manuscript for important intellectual content (all authors); Obtained funding (Singal, Parikh); Administrative, technical, and material support (Singal and Parikh); Study supervision (Singal) Conflicts of Interest: Amit Singal was on speakers bureau for Gilead, Bayer, and Bristol Meyers Squibb. He has served on advisory boards for Gilead, Abbvie, Bayer, Eisai, Wako Diagnostics, Roche, and Exact Sciences. He serves as a consultant to Bayer, Eisai, Roche, and Glycotest. He has received research funding from Gilead and Abbvie. Neil Mehta has received research funding from Wako Diagnostics. Anjana Pillai serves as a consultant and is on speakers bureau for Eisai and BTG. Jordan Feld has received research support from Gilead, Abbvie, Merck, and Janssen. Binu John has served on advisory boards for Eisai. Catherine Frenette is on speakers bureaus for Bayer, Bristol Meyers Squibb, Gilead, Merck, Abbvie, and Eisai. She served on advisory boards for Gilead, Eisai, and Wako. She served as a consultant for Bayer and Gilead. She received research funding from Bayer. Parvez Mantry is on speakers bureaus and served on advisory boards for Gilead, Abbvie, Bayer, BMS, Eisai, Merck, and BTG. He has received research funding from Gilead and Sirtex. Michael Leise has received research funding from Abbvie. Kalyan Ram Bhamidimarri serves as scientific advisory board member for Gilead, Merck, and Abbvie. He has received research funding from Gilead. Laura Kulik is on speakers bureau for Eisai, Gilead, and Dova. She serves as an advisory board member for BMS, Eisai, Bayer, Exelixis Reena Salgia is on speakers bureau for Bayer. She has served on advisory boards for Bayer, Eisai, and Exelixis. Sanjaya Satapathy has received research support from Gilead and Bayer.He has served on advisory boards or as a consultant for Abbvie and Gilead.

A 44-year-old man with uncontrolled diabetes and chronic pancreatitis presented with abdominal pain, jaundice and unintentional weight loss. Laboratory investigations were significant for hyponatraemia, an obstructive pattern of liver enzymes. Imaging was consistent with intrahepatic and extrahepatic biliary obstruction, and endoscopic evaluation revealed a long common bile duct stricture. Intravascular volume depletion, beer potomania and syndrome of inappropriate antidiuretic hormone (with concern for biliary or pancreatic malignancy) were considered in the work-up for the aetiology of the hyponatraemia. After 4 days of conventional treatment, hyponatraemia persisted. Lipid panel obtained revealed very high levels of total cholesterol. The patient underwent a successful biliary diversion and reconstruction surgery. Follow-up after 3 months showed a clinically stable patient with resolution of elevated liver enzymes, hyperlipidaemia and hyponatraemia. We illustrate this rare case of hyponatraemia secondary to hyperlipidaemia in obstructive biliary cholestasis. It is important for physicians to thoroughly investigate the aetiology of hyponatraemia at its onset.

INTRODUCTION: Sarcoidosis is an inflammatory granulomatous disease that has multi- organ involvement with varied course of disease expression and progression. Liver involvement is seen in only a hand full of cases, especially with florid symptoms. Here, we present a rare case of symptomatic isolated hepatic sarcoidosis mimicking malignancy, that was promptly diagnosed. CASE DESCRIPTION/METHODS: A 60- year old African American female, who is otherwise healthy, presented to our tertiary care center with a month-long history of worsening epigastric pain, nausea, vomiting, malaise, weight loss and night sweats. Exam was remarkable for hepatomegaly and labs significant for elevated ALP and GGT, mild transaminitis and elevated CA 19-9 levels. CT scan revealed hypodensities and perfusion defects throughout the liver, hepatosplenomegaly and hilar lymphadenopathy, which had been confirmed by MRI and Triple-phase CT of the liver. With the suspicion for malignancy, liver biopsy was pursued and showed epithelioid-cell granulomas with focal necrosis and multiple asteroid bodies, pathognomonic for sarcoidosis. Subsequently, ACE levels were found to be elevated. Patient was then started on prednisone and immunosuppressants with relief of symptoms. A repeat CT scan 6-months later, showed resolution of liver lesions and improvement in liver chemistries. DISCUSSION: Sarcoidosis is a systemic granulomatous disease of unknown etiology. Per ACCESS study, liver involvement of sarcoidosis was described in only 11.5% of 736 patients, more commonly seen in African American population than Caucasian, with only 10% of them were reported to have transaminitis. Hepatic involvement appears to be clinically silent with most patients presenting with constitutional symptoms, even then liver lesions on CT are described in only 5% of the patients. Steroid therapy and immunomodulators are used to help with symptom control, however their effect on the natural progression of the disease is not established. Our patient presentation with significant symptoms and imaging findings, prompted us to think beyond the obvious. Sarcoidosis is a diagnosis of exclusion; hence it is essential for clinicians to have a high degree of suspicion for hepatic involvement.

Liver abscesses are the most common types of visceral abscesses. Pyogenic liver abscesses, a particular type of liver abscesses, are uncommonly encountered. We present a rare case of pyogenic liver abscess caused by methicillin-susceptible Staphylococcus aureus in a young man. A 21-year- old man presented from prison to the hospital with fever, nausea, vomiting, diarrhea, and abdominal pain for five days. Labs were significant for leukocytosis with predominant neutrophilia and elevated liver enzymes. CT abdomen with contrast revealed an 8.4 cm multiloculated right hepatic mass extending to the kidney. Patient was started on broad spectrum antibiotics, given septic presentation. Peripheral blood cultures returned positive for methicillin-susceptible Staphylococcus aureus (MSSA). The culture from percutaneous drainage also revealed MSSA. He received a total of four weeks of IV Nafcillin therapy along with drainage of his abscess via percutaneous catheter. Follow-up revealed clinical resolution. This case highlights the importance of obtaining an aspirate from the liver abscess to better guide treatment strategy. Clinicians must consider broadening antibiotic coverage to include gram-positive organisms if the patient presents with severe illness and risk factors for Staphylococcus aureus infections.

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