case_images: PMC4735056_01
case_images: Radiographic and ultrasound findings in case 1. (A) Chest radiograph at the time of admission showed bilateral pulmonary infiltration with consolidation. (B) Ultrasound image showed a dilated hepatic vein (left branch, 1.22 cm; middle branch, 0.61 cm and right branch, 1.36 cm). (C) Ultrasound image showed slowed hepatic vein flow (middle branch, 9.14 mm/s). (D) Echocardiogram showed a dilated left ventricle (LVIDd 56.46 mm) and cardiac failure (LVEF 42%) with weakened left-ventricular wall motion. LVEF, left ventricular ejection fraction; LVIDd, left ventricular internal diameter at end-diastole.
case_images: emi20161f1.jpg
case_images: PMC4735056_01_emi20161f1.jpg
case_images: fig1
case_images: Chest radiography showed bilateral pulmonary infiltrates with consolidation at admission (Figure 1A). Liver ultrasound revealed a dilated hepatic vein (left branch, 1.22 cm; middle branch, 0.61 cm; and right branch, 1.36 cm) with slow hepatic vein flow (middle branch, 9.14 mm/s) (Figure 1B and 1C) and excluded surgical biliary tract diseases and space-occupying lesions. An echocardiogram showed a dilated left ventricle with an internal diameter at end-diastole (LVIDd) of 56.46 mm and low left ventricular ejection fraction (LVEF) of 42% with weakened left ventricular wall motion (Figure 1D).
case_images: Dynamic changes in biochemical test results in case 1. (A) Changes in ALT, AST and LDH values during the hospital stay. (B) Changes in TB and INR values during the hospital stay. ALT, alanine aminotransferase; AST, aspartate aminotransferase; INR, international normalized ratio; LDH, lactate dehydrogenase; TB, total bilirubin.
case_images: emi20161f2.jpg
case_images: PMC4735056_01_emi20161f2.jpg
case_images: fig2
case_images: The dynamic changes in liver function are shown in Figure 2.
case_images: Histological findings in case 1. (A) Centrilobular necrosis in the liver without inflammation (haematoxylin and eosin, 10x). (B) Dilated sinusoids with coagulative necrosis (haematoxylin and eosin, 40x). (C) Reactive type II pneumocytes and hyaline membrane in the lung (haematoxylin and eosin, 20x). (D) Renal tubular degeneration and necrosis (haematoxylin and eosin, 20x).
case_images: emi20161f3.jpg
case_images: PMC4735056_01_emi20161f3.jpg
case_images: fig3
case_images: Sinusoid congestion and mild hepatocellular atrophy were identified in adjacent tissue (Figure 3A and 3B). The lung showed interstitial pneumonitis with hyaline membranes, congestion, intrapulmonary haemorrhage and anthracosis (Figure 3C). Acute tubular necrosis and generalized renal tubule atrophy were found in the kidney (Figure 3D).
case_images: PMC4735056_02
case_images: Radiographic and ultrasound findings in case 2. (A) Chest radiograph at the time of admission showed bilateral pulmonary infiltration. (B) Chest radiograph on day 2 compared with that at admission showed progression of the bilateral pulmonary infiltration and consolidation. (C) Chest radiograph on day 4 showed progression of bilateral pulmonary infiltration and consolidation compared with day 2. (D) Echocardiogram at the time of admission showed cardiac failure (LVEF 37.5%). LVEF, left ventricular ejection fraction.
case_images: emi20161f4.jpg
case_images: PMC4735056_02_emi20161f4.jpg
case_images: fig4
case_images: Chest radiography on admission showed bilateral pulmonary infiltrates (Figure 4A). On admission, an echocardiogram showed a dilated left ventricle with a low LVEF of 37.5% (Figure 4D), together with weakened cardiac wall motion. Due to the progression of the infiltrates and consolidation (Figure 4B and 4C), the patient was placed on a mechanical ventilator on the third day after admission.
case_images: Dynamic changes in biochemical test results in case 2. (A) Changes in ALT, AST and LDH values during the hospital stay. (B) Changes in TB and INR values during the hospital stay. ALT, alanine aminotransferase; AST, aspartate aminotransferase; INR, international normalized ratio; LDH, lactate dehydrogenase; TB, total bilirubin.
case_images: emi20161f5.jpg
case_images: PMC4735056_02_emi20161f5.jpg
case_images: fig5
case_images: ALT, AST and LDH activities were elevated to 1281, 3029, and 2787 U/L, respectively, the highest levels seen during the patient's hospital stay (Figure 5). The dynamic changes in liver function and INR are described in Figure 5.