Day 3 :
- Cardiology | Oncology | Obstetrics and Gynecology | Neurology | Endocrinology
Chair
Guy Huges Fontaine
Universite Pierre et Marie Curie, France
Co-Chair
Erich T Wyckoff
Universty of Florida, USA
Session Introduction
Erich T Wyckoff
Universty of Florida, USA
Title: The Bartholin Cyst that Wasn’t: A Case Report of Metastatic Cancer
Time : 11:00-11:30
Biography:
Erich Tyrone Wyckoff has obtained his Medical degree from the University of Alabama at Birmingham School of Medicine before completing his Residency in Obstetrics & Gynecology at Wright State in Dayton, Ohio. He has joined the Faculty of the University of South Florida where he focused on minimally invasive surgery. He later joined the Faculty at the University of South Florida, where his interests include medical diversity, education and robotic surgery. He is board certified in Obstetrics & Gynecology and engaged in surgical technologies and has published peer-reviewed articles in his specialty. He is the author of “God’s Physician: Word’s of my life”.
Abstract:
Bartholin gland cysts and abscesses are common disorders of the female genital tract. Carcinomas and benign tumors of the gland are rare. However, in certain patient populations it can be argued that patients presenting with suspected Bartholin gland cyst or abscess should undergo both drainage and biopsy of the lesion in order to exclude potential carcinoma. While metastatic disease have been documented in primary cancers of the Bartholin gland secondary to its extensive vascular and lymphatic network, we present a case report of a poorly differentiated endometrial carcinoma metastasis to the Bartholin gland that initially presented as a Bartholin gland abscess. This case also serves as a useful reminder that when treating disease of the female genital tract, no matter how minor, a level of vigilance and attention to managing the whole patient is of upmost importance.
Nimat Alam
Texas Tech University Health Science Center, USA
Title: Upper and Lower Extrimity paralysis: Case Report
Time : 11:30-12:00
Biography:
Nimat Alam is a Physician associated with Family and Community Medicine at Texas Tech University Health Sciences Center. Her specialization is with geriatrics, clinical expertise include diabetic care, geriatric medicine, hospital medicine, nursing home ambulatory procedures and preventive medicine.
Abstract:
Case Presentation: A 31 year old Hispanic male arrived to Emergency Room by Emergency Medical Service with complaint of lower and upper extremities weakness that started about 5 days prior to admission, which progressively worsened. On the day of admission, he was unable to ambulate. Apart from the weakness the patient denied dyspnea, fever, neck pain, no recent history of travel with no recent upper respiratory infection or gastrointestinal infection or sick contacts. His past medical history includes Grave’s disease which was previously treated with methimazole but he discontinued the medication a few weeks ago. Patient denied any recreational drugs, over the counter medications, prescription medications including laxatives or diuretics. He did however admit to recent tobacco abuse. Discussion: One of the main goals of medical management is to replenish the potassium levels as imbalances in potassium can lead to arrhythmia and cardiovascular complications. Potassium chloride is a good choice for supplementation and is dosed between 40 and 200 mmols. Judicious replacement of potassium is necessary as rebound hyperkalemia is a common problem because potassium can undergo a transcellular shift from extracellular to intracellular space. Oral or IV preparations of propranolol are beneficial in aiding in potassium homeostasis. Nonspecific beta antagonistic properties of propranolol allow for increase in potassium levels and resolve the paralysis without the rebound effect of hyperkalemia. Oral propranolol can be dosed at 60 mg every six hours. Conclusion: There is much other differential diagnosis that could present with lower extremity weakness such as Guillain-Barre syndrome, meningitis, medication side effects or even malignancy. But HPP is one of the diagnoses often missed due to its low occurrence. The combination of paralysis with hypokalemia should prompt to any physician the possibility of this disease. The prompt diagnosis of this condition will help to avoid expensive laboratory studies and invasive procedures. It will also help to soon provide the patient with the appropriate treatment such as moderate potassium replacement in addition with propranolol to correct the hypokalemia, thus improving the extremity weakness.
Reena Bansal
Crozer Chester Medical Center, USA
Title: Interesting case of Hyponatremia unmasking a lung cancer
Time : 12:00-12:30
Biography:
Reena Bansal has completed her MBBS from Mysore Medical College and Research Institute in the year 2008 and Masters from Rajiv Gandhi University of Health Sciences in the year 2011. She is currently associated as Resident Physician with Crozer Chester Medical Center since 2014.
Abstract:
Introduction: Hyponatremia is a common condition seen in clinical practice. SIADH is a common cause of this hyponatremia, especially in small cell lung cancer. It usually accompanies but can also precede the diagnosis of the tumor with an incidence of about 3.7% to 5%. We report this interesting case of hyponatremia, which led to the diagnosis of lung cancer. Case Report: A 78 year old Caucasian female was admitted with complaints of intermittent nausea and vomiting for 3 months. She was found to have sodium levels of 119. She denies being on any water pills, excessive fluid intake or recent medication changes. She had a 50 pack year smoking history. Management: Severe hyponatremia in the setting of nausea in a patient who has been a chronic smoker with no hx of diabetes, heart failure, cirrhosis or kidney disease and with normal thyroid functions and lipids and the increased urine osmolality, led us to the diagnosis of SIADH. However, work up for the cause of SIADH, in the setting of 50 pack year history of smoking made us to a CAT scan of the lung, which revealed a dominant 2.0×1.6 cm medial right lower lobe pulmonary nodule with multiple smaller bilateral pulmonary nodules with mediastinal and hilar lymphadenopathy. She has given a few doses of tolvaptan with appropriate response in sodium. Discussion: Hyponatremia secondary to SIADH is a known paraneoplastic manifestation of lung cancer. The incidence of hyponatremia in lung cancer is reported to be only 1% in NSCLC and 15% in SCLC. It is important to treat hyponatremia but it is equally important to evaluate the cause of hyponatremia. In our patient, the single complaint of nausea led us to the diagnosis of lung cancer eventually.
Jesús Alcaraz-Rubio
Hospital Mesa del Castillo, Spain
Title: Platelet-Rich Plasma in a Patient with Cerebral Palsy
Time : 13:15-13:45
Biography:
Jesus Alcaraz is currently associated with Department of Hematology and Oncology at Hospital Mesa del Castillo in Spain.
Abstract:
Background: The use of platelet-rich plasma is a now a common medical technique known as regenerative medicine, through power cell activation and differentiation, which produces growth factors called platelets derived both locally and systematically. Here, we report the case of a cerebral palsy patient who received intravenous platelet-rich plasma. Case report: We administered an intravenous injection of concentrated platelet-rich plasma (25 cc) in a 6 year old boy with perinatal cerebral palsy, cognitive impairment and marked and severe generalized spasticity. We performed follow-up at 3 and 6 months after the injection. All serum samples for determination were obtained by ELISA technique. Cognitive scales (Bayley, Battelle, M.S.C.A, Kaufman ABC and Stanford-Binet Intelligence scale) were used before and after treatment. The determination protocol that was applied before the analysis was performed manually and the auto transfusion was considered suitable for treatment. We determined the plasma levels of factor similar to insulin-1 (IGF-1), platelet-derived growth factor (PDGF), vasculo-endothelial growth factor (VEGF) and transforming growth factor B (TGF-B) before and during treatment monitoring. Conclusions: No adverse effects were observed in the patient except for a small hematoma in the area channeling venous access. We observed a clear improvement in the cognitive sphere (memory, ability to perform more complex tasks and acquisition of new skills) and in language, maintaining stable levels of growth factor in plasma 3-5 times higher than average for his age group at both 3 and 6 month follow-up. Positron emission tomography (PET) images showed an evident increased demarcation in the cerebral cortex. We propose that this therapy is useful in these patients to harness the neurostimulative and neuroregenerative power of endogenous growth factors derived from platelets.
Caroline Tsimi Mvilongo
University of Yaoundé, France
Title: Bilateral retinoblastoma with extra retinal diffusion: 2 cases reports
Time : 13:45-14:15
Biography:
Caroline Mvilongo Tsimi has completed her MD degree from Yaounde Faculty of Medicine and Biomedical Sciences. She is an Ophthalmologist at Yaounde Central Hospital and has published some papers in reputed journals.
Abstract:
Introduction: Retinoblastoma is an embryonal tumor of neuroectodermal origin, highly malignant affecting the young child and the infant. It is bilateral in 40% of cases. It is of good prognosis if the diagnosis has been taken earlier. We report 2 clinical cases of bilateral retinoblastoma with extra retinal diffusion which is a poor prognosis factor. Case 1: DW , 20 months brought in our ophthalmology service in 2009 with a tumor of the left eye since one month with a past history of leucocoria since birth. A first CT scan has been ask 8 months before but not done by the family. At the ophthalmology exam, he was classified at stage V of Reese-Ellsworth for the contralateral right eye and orbital extension of the left eye. A CT scan has been done showing bilateral calcifications with bilateral orbital extension. He has been enucleated for the left eye and received 3 doses of chemotherapy. The patient was lost of view 2 months after the surgery. Case 2: HO, 3 years Centrafican refugee referred in our ophthalmology service on June 2015 for the care of a tumor of the right eye since 3 months. She had a leucocoria in the right eye since one year; she is the last of a family of 9 with past history of 1st degree consanguinity. The ophthalmology exam showed a great tumor with necrosis and inflammation of the right eye. At the left eye, sub-retinal with mass with retinal detachment stage V of Reese-Ellsworth, she has received neoadjuvant chemotherapy and exenteration of the right eye. She died few hours after the surgery. Discussion: These 2 cases have been seen late in an appropriate ophthalmology unit. The prognosis was poor because of the extra retinal diffusion of the tumor mainly through the optic nerve and the sclera. According to the literature, the mean age of diagnosis is 11 months for bilateral retinoblastoma. The factors that could explain the late of our patient are the using of traditional medicine, the socio-economic status, the ignorance of the gravity by the parents and the inadequate health care unit. Conclusion: Bilateral retinoblastoma is relatively present in our milieu. It should be taken care earlier and people at risk should be sensitized about the disease which is highly malignant and could lead to death if not adequately treated.
Moustafa Elsheshtawy
Coney Island Hospital, USA
Title: Hypothyroidism and Congenital long QT: Additive effect causing torsades?
Time : 14:15-14:45
Biography:
Moustafa Elsheshtawy has earned his degree in Medicine from Tanta University, Tanta, El-Gharbia Governorate, Egypt and completed his Residency training at Coney Island Hospital, Brooklyn, New York, USA. He is currently beginning his Fellowship in Cardiovascular Medicine at Maimonides Medical Center, in Brooklyn as well. He has always been interested in clinical medical research and has participated in many national and international clinical trials, most notably with the National Heart, Lung and Blood Institute (NHLBI), Roche Pharmaceutical, Boehringer Ingelheim Pharmaceutical, Hospital Quality Foundation among others. His academic work has been recognized at the national American Medical Association (AMA) 2015 conference in Atlanta, Georgia.
Abstract:
Hypothyroidism can result in a myriad of cardiovascular effects. We present a rare instance of a young female patient with torsades de pointes (TdP), a fatal ventricular tachyarrhythmia, potentiated by hypothyroidism superimposing a congenital long QT syndrome. Although hypothyroidism has been linked to torsades de pointes in few case reports, none of the reported patients have been tested for congenital long QT syndrome. Reversing cardiovascular risk has been documented when patients regained their euthyroid state after levothyroxine replacement therapy. Patients should be given stress dose glucocorticoids while levothyroxine dose increases gradually to avoid precipitating acute coronary syndrome especially in patients with underlying coronary artery disease. Clinicians should be aware of life-threatening complications of hypothyroidism. Prompt diagnosis and treatment can lead to absolute recovery and a favorable long-term prognosis.
Märta Sund Levander
Linköping University, Sweden
Title: The cMeeting Hallenge of detecting infections in frail elderly individuals
Time : 15:00-15:30
Biography:
Marta Sund Levander has completed her PhD in Clinical Physiology at Linkoping University, Sweden in 2004. She is a Senior Researcher and University Lecturer at Linkoping University. She has published papers and textbooks about assessment and validation of body temperature in health and disease with focus on frail elderly. She is responsible for Swedish guidelines about body temperature measurement in healthcare and a Swedish Representant in ISO standards for thermometry.
Abstract:
It is well known that non-specific signs and symptoms and lack of specific ones are common in frail elderly individuals, especially nursing home residents (NHR), contributing to a delayed diagnosis and treatment and a risk of overuse of antibiotics and hence development of antibiotic resistant. Atypical signs and symptoms are observed as weakness, falling, weight loss, physical dysfunction and cognitive decline. As specific symptoms are often lacking, the presence of an increased body temperature in fever, in terms of ≥38 °C, is often evaluated as a significant symptom of illness and an important reason for taking further action in clinical practice. However, temperature in fever in frail elderly has been reported to be lower than traditionally stated. The complexity of detecting infections in this population can partly be explained by difficulties in understanding and interpreting non-specific signs and symptoms and co-existing chronic diseases that blur the clinical picture. In addition, as more than 50% of NHR are assessed as having chronic pain, the effects on body temperature from medication with paracetamol daily has to be considered. Furthermore, reference values for common biomarkers in blood/serum are based on samples from healthy, young individuals and do not consider the presence of chronic diseases, daily medication and ageing. The aim of this presentation is to raise and discuss the challenge of detecting infections early on in frail elderly.
Robin George Manappallil
National Hospital, India
Title: Diabetic ketoacidosis and acute pancreatitis: The masquerading conditions in a patient with chronic kidney disease
Time : 15:30-16:00
Biography:
Robin George Manappallil has completed his Bachelor of Medicine and Bachelor of Surgery degree from Father Muller Medical College, India and his MD in Internal Medicine from Pondicherry Institute of Medical Sciences, India. He has received three gold medals for being the highest scorer in his MD exams in college as well as university and for being the best outstanding post graduate. He has published around 15 papers in national and international journals. He is currently serving as a Consultant Physician at National Hospital, Calicut, India.
Abstract:
Diabetic patients are at the risk of developing acute pancreatitis, due to hypertriglyceridemia. Diabetic ketoacidosis in an acute life threatening complication of type-1 diabetes; an elevated serum amylase levels may be suggestive of acute pancreatitis, but these levels may also be elevated in diabetic ketoacidosis. In such cases, serum lipase levels aid in the diagnosis of acute pancreatitis. However, in patients with chronic kidney disease, the levels of amylase and lipase will be elevated, as the pancreatic enzymes are excreted by the kidneys. This is a case report of a young lady with type-1 diabetes and chronic kidney disease (stage 4), not on hemodialysis, who presented with diabetic ketoacidosis and had elevated levels of amylase and lipase, in the absence of pancreatitis.
- Epidemiology | Pediatrics | Geriatrics | Intensive Care Medicine | Surgery
Chair
Tarek Hamed Attia
Zagazig University, Egypt
Co-Chair
Takeshi Nishimura
Hyogo College of Medicine, Japan
Session Introduction
Tarek Hamed Attia
Zagazig University, Egypt
Title: Cerebral venous sinus thrombosis in heterozygous prothrombin G20210A mutation in Egyptian child, with an excellent outcome
Time : 10:00-10:30
Biography:
Tarek Hamed Attia has completed his MBBCh, Masters in Pediatrics and MD in Pediatrics from Zagazig University School of Medicine, Egypt. He is currently a Professor of Pediatrics, Zagazig University, Egypt. He is a Member in Research Board Pediatrics and Hematology and he has many publications in Pediatrics and Hematology. He is also a Chairman for Postgraduate Education and Examination Board in Pediatric Department, Zagazig University. He has published many papers in reputed journals and has been serving as an Editorial Board Member of reputed journals. He has attended many international conferences as speaker and as chairperson.
Abstract:
Prothrombin gene G20210A mutation is a risk factor for the development of deep vein thrombosis. We present a 6 year old Egyptian boy who had vomiting associated with headache and dizziness. His conscious level was normal with neither focal neurological signs nor papilledema. Brain computed tomographic scan, magnetic resonance imaging and magnetic resonance venography (MRV) revealed thrombosis of the superior sagittal and left transverse sinuses. The patient was heterozygous for prothrombin gene G20210A mutation. He has received enoxaparin and warfarin. Brain imaging follow-up, after 1 month, showed complete resolution of the thrombus. The child was followed up for 1 year and he was very healthy. Cerebral venous thrombosis must be considered in the differential diagnosis of any neurological symptoms, even mild symptoms and prothrombin gene G20210A mutation must be considered in the screening of Egyptian children. Early diagnosis and treatment can be a good prognostic index.
Takeshi Nishimura
Hyogo College of Medicine, Japan
Title: Gastric perforation due to non-invasive positive pressure ventilation: Review of complications in NIPPV
Time : 10:30-11:00
Biography:
Takeshi Nishimura was graduated from Okayama University in Japan in 2009. He was trained for 5 years as Surgical Clinician and has worked as Emergency Clinician for two years. He is specialized with traumatology and gastroenterology. He has published more than 5 papers in journal about emergency medicine and emergency surgery.
Abstract:
Non-invasive positive pressure ventilation (NIPPV) is widely used in patients with respiratory failure due to neuromuscular disease. NIPPV is safe and effective device that might be able to avoid potential complications associated with invasive mechanical ventilation such as nosocomial pneumonia and tracheal trauma. NIPPV can be used intermittently, the equipment is portable and ventilation does not interfere with eating and speaking. The most frequent trouble that might occur is ulcer at face in fitting mask. However, time consuming, some lethal complications associated with NIPPV had been reported in recent years. A 23 year old man was admitted to our hospital complaining of severe abdominal pain. He has a history of congenital hypomyelination neuropathy. Because of respiratory trouble due to neuropathy, doctor had prescribed NIPPV and increased end respiratory pressure before five days. Abdominal computed tomography revealed free intra-abdominal air leading to emerging laparotomy. Intra operative findings showed a gastric perforation and hematoma at gastric anterior walls. Patient recovered after obstructive bowel obstruction and transferred to pediatrics post admission on Day 26. Previous study associating with complications of gastrointestinal perforation has rarely been reported ever. We emergent clinicians should be aware of these complications. NIPPV is not always non-invasive equipment. Acknowledgement of prevention and recognition related to complications with NIPPV leads appropriate use of it depends on patient’s condition.
Reena Bansal
Crozer Chester Medical Center, USA
Title: Fenestration of false lumen to reverse acute limb ischemia in type B aortic dissection
Time : 11:15-11:45
Biography:
Reena Bansal has completed her MBBS from Mysore Medical College and Research Institute in the year 2008 and Masters from Rajiv Gandhi University of Health Sciences in the year 2011. She is currently associated as Resident Physician with Crozer Chester Medical Center since 2014.
Abstract:
Introduction: Aortic dissection (AD) is one of the most serious medical emergencies encountered in clinical practice. The incidence in general population is estimated to be 5.9 per 100,000 persons annually. The commonly used Stanford system classifies AD in to type-A (involving ascending aorta) and Type-B (all other). Type-A AD is considered a surgical emergency due to potentially fatal complications like cardiac tamponade and myocardial infarction. Type-B AD is managed medically with tight blood pressure control. However, the associated complication of limb or visceral ischemia due to extrinsic compression by false lumen or occlusion by intimal flap, necessitates a more aggressive surgical versus percutaneous approach. The percutaneous fenestration is not a very commonly performed procedure because of the paucity of exposure. We report this case of lower limb ischemia with type-B aortic dissection, managed successfully with percutaneous fenestration. Case presentation: 59 year old man with past medical history of hypertension and smoking presented to the emergency room with chief complaints of sudden onset of right sided chest pain and right lower limb pain. Physical exam was significant for absent right femoral pulse. Cardiac enzymes were negative. A CT scan and lower extremity angiography were performed. The imaging revealed aortic dissection distal to the left subclavian artery with significant occlusion of the right iliac artery by compression thru false lumen. A percutaneous fenestration approach was chosen. 5 F angle tapered Terumo 0.35 wire was passed into the false lumen. Fenestration of the false lumen was performed to return the blood flow to the right iliac artery. Patient tolerated the procedure well and at a 30 day follow up he was still doing well. Discussion: Type-B aortic dissection is generally managed medically. Critical limb or visceral ischemia is a medical emergency that demands a more aggressive management. The options in such scenario are surgical repair versus percutaneous fenestration. Percutaneous fenestration technique is a less invasive option in such medically treated patients in whom this complication arises.
Yuhamy Curbelo-Peña
Vic University Hospital, Spain
Title: Endometriosis causing acute appendicitis complicated with hemoperitoneum- Case report
Time : 11:45-12:15
Biography:
Yuhamy Mitsahid Curbelo Pena has completed her Medicine grade from Central University of Venezuela and is currently pursuing Postgraduate program at Vic University Hospital in Vic, Barcelona, Spain. She is a Resident at General Surgery Department. She has published 2 papers in reputed journals and has presented 11 papers in national and international clinical and surgical congresses. She had an editorial experience from April, 2011 to August, 2011 as Member of the Editorial Committee of the (indexed) Magazine “Latin American Science and Science and Student Medical Investigation”. (CIMEL); published by FELSOCEM.
Abstract:
Endometriosis is a painful disorder characterized by endometrial tissue outside the uterine cavity. It usually affects the pelvis, but in rare cases it might extend to other parts of the body. The report is based on a case of a 39 year old woman, who presented symptoms of acute appendicitis and diagnosis confirmed with ultrasonography and a computed tomography scan procedures. Laparoscopic appendicectomy was performed. After entering the abdominal cavity, hemoperitoneum was discovered with no associated pelvic or abdominal lesions. Biopsy confirmed acute appendicitis with endometrial glands and stroma infiltrating its muscular tissue. Patient recovered without complications and was discharged 48 hours after surgery. The appendix is rarely affected by endometrial infiltration. The literature describes an incidence of 0.8%, just a few cases have been associated with acute appendicitis; however, none of them are described to present hemoperitoneum, being our patient the first one reported with such complication.
Tarek Hamed Attia
Zagazig University, Egypt
Title: Idiopathic arterial calcification of infancy: A rare autosomal recessive disease case report
Time : 12:15-12:45
Biography:
Tarek Hamed Attia has completed his MBBCh, Masters in Pediatrics and MD in Pediatrics from Zagazig University School of Medicine, Egypt. He is currently a Professor of Pediatrics, Zagazig University, Egypt. He is a Member in Research Board Pediatrics and Hematology and he has many publications in Pediatrics and Hematology. He is also a Chairman for Postgraduate Education and Examination Board in Pediatric Department, Zagazig University. He has published many papers in reputed journals and has been serving as an Editorial Board Member of reputed journals. He has attended many international conferences as speaker and as chairperson.
Abstract:
Idiopathic arterial calcification of infancy is a rare autosomal recessive disease, characterized by deposition of calcium along the internal elastic membrane of arteries, accompanied by fibrous thickening of the intima which causes luminal narrowing. Here we are reporting a case of idiopathic arterial calcification of infancy in a Saudi female newborn of non-consanguineous pregnant woman who had polyhydramnios. The newborn baby had severe respiratory distress, systemic hypertension and persistent pulmonary hypertension of newborn. She was admitted to Neonatal Intensive Care Unit, where she was ventilated and proper treatment was provided. Molecular genetic testing was positive for mutations of ectonucleotide pyrophosphatase/phosphodiesterase 1 gene which is reported in 80% of cases of idiopathic arterial calcification of infancy. The baby died at about 5 month of age because of myocardial ischemia and cardiorespiratory arrest. Idiopathic arterial calcification of infancy should be considered in any newborn who presented with persistent pulmonary hypertension of newborn, severe systemic hypertension and echogenic vessels on any radiological study. Calcifications of large and medium sized arteries are important diagnostic finding.
Reena Bansal
Crozer Chester Medical Center, USA
Title: Transaminitis with the use of HAART
Time : 13:30-14:00
Biography:
Reena Bansal has completed her MBBS from Mysore Medical College and Research Institute in the year 2008 and Masters from Rajiv Gandhi University of Health Sciences in the year 2011. She is currently associated as Resident Physician with Crozer Chester Medical Center since 2014.
Abstract:
Background: Atazanavir (ATV) is a protease inhibitor, which is an important component of the Anti-Retroviral Therapy (ART) for HIV. All ARTs have the potential side effect of deranged liver functions. But do we remember this while working up a patient for transaminitis? We report this case to remind physicians about this adverse effect of atazanavir. Methods: A 59 year old gentleman with past medical history of HIV on atazanavir, ritonavir, lamivudine/zidovudine combination and tenofovir, presented with nausea, vomiting, diarrhea and fatigue. He has had multiple admissions in the past for unrelated complaints, but has always had hepatitis work up done due to the abnormal LFTs. He has been on ARTs for 19 years and has been admitted to the hospital 8 times in this period, each time with deranged LFTs and each time ended up having a hepatitis panel checked. Results: The patient has a viral gastroenteritis, which resolved spontaneously with supportive treatment. However, the patient continued to have high indirect bilirubin due to use of atazanavir. Patient’s Highly Active Anti-Retroviral Therapy (HAART) regimen was therefore changed, leading to a slow improvement in bilirubin levels. Conclusion: Hyperbilirubinemia is a common side effect of atazanavir. There is no recommendation to stop ATV for up to grade III hyperbilirubinemia (serum bilirubin>2.5 with raised alkaline phosphatase and hospitalization due to drug induced liver injury), but cases need to be individualized. However, grade IV hyperbilirubinemia (grade III along with either prolonged jaundice for 3 months or more, signs of hepatic decompensation or other organ failure related to liver injury) is rarely found. The predictive value of ATV related hyperbilirubinemia needs to be further investigated.