bluuebunny/crossref_metadata_2025 huggingface dataset:
2043 A Case of Optic Neuritis in Setting of Starting Infliximab-dyyb in Ulcerative Colitis Patient
Authors: Alameri Aws , Hughston Adam , Lorio Eric , Parker Allan L.
Published: October 2019

INTRODUCTION:

Evidence supports an association between CNS demyelination disorders and use of with Tumor Necrosis Factor-α (TNF-α) inhibitors. Here we present a case of optic neuritis onset after initiating therapy with infliximab-dyyb and describe subsequent treatment response.

CASE DESCRIPTION/METHODS:

A 31-year-old female with a history of Ulcerative Colitis, presented with new left periorbital heaviness 2 weeks after receiving the first dose of infliximab-dyyb. The pain eventually progressed to darkening and blurring of vision. The physical examination was positive for reduced visual acuity, color desaturation, and positive relative afferent pupillary reflex on the left eye only. CSF studies were remarkable for positive Oligoclonal bands and increased IgG Index. Orbital and brain MRI were suggestive of optic neuritis. Infliximab-dyyb was discontinued and she was treated with a course of IV Methylprednisolone and discharged home on Glatiramir acetate. On follow up visits, eye pain and blurry vision dramatically improved. In order to avoid extra-colonic side effects, she was switched to vedolizumab which she has tolerated well.

DISCUSSION:

It has been described that IBD patients can present with CNS demyelination, which can be explained by both conditions sharing epidemiological and immunological characteristics. However, this association can be confounded by the use of TNF-α inhibitors, which are commonly used in treating IBD and have been themselves associated with CNS demyelination. Though mechanism is unclear, blocking TNF-α receptors in the CNS has been found to result in neuroinflammation and long-term neural damage. The average time from exposure to the onset of symptoms has been described as seventeen months in one case series on infliximab. However, in our patient she started experiencing symptoms after the initial dose. This rapid reaction may be due to infliximab-dyyb being used. To our knowledge this is the first reported reaction related to a bio-similar. This demonstrates that further studies are needed to estimate the true incidence of demyelinating disorders in patients with IBD and to elucidate if bio-similar may be subject to stronger demyelinating reactions.
2046 Peristomal B-Cell Lymphoma in a Patient With Complicated Ulcerative Colitis
Authors: Hafiz Nazar , Ghildiyal Naomi , Jogimahanti Anusha , Rashid Shazia , Maruvada Smita , Jordan Paul , Manas Kenneth J. , Morris James D. , Mendoza Mardeli Saire , Chaudoir Catherine , Palmer Thomas , Singh Tejinder
Published: October 2019

INTRODUCTION:

Ulcerative colitis (UC) is an inflammatory disease that predominantly involves the colon and rectum often requiring treatment with corticosteroids and immunomodulators. However chronic use of immunomodulators is usually associated with increased risk for lymphoma. Extranodal involvement of GI tract is typically seen however primary GI lymphoma is very rare. Here we present a unique case of B-cell lymphoma diagnosed from stomal biopsies.

CASE DESCRIPTION/METHODS:

A 76-year-old caucasian male with history of Ulcerative Colitis for almost 28 years, status post multiple abdominal surgeries including ventral hernia repair, ileostomy and colostomy presented with ongoing stoma complications for about 6 months. These complications included new fistula formation around the colostomy and ileostomy sites. Despite aggressive wound care, lesions did not regress, and continued to grow producing sharp, burning type of pain. There was ongoing purulent discharge from new fistula formation. Peri-ostomal biopsy from both ileostomy and colostomy was positive for B-cell lymphoma. On further history, patient endorsed fever, night sweats, and 30-lb weight loss over 5 months. PET scan showed increased uptake in both the stomas as well as liver. Chemotherapy options were discussed with Oncology, however patient opted for hospice as the prognosis was deemed poor.

DISCUSSION:

Primary GI lymphoma is common in stomach. Small intestine and colonic lymphoma account for 9% and 1% respectively. There have been multiple reports published citing association of lymphoma in IBD patients treated with immunomodulators. Our patient had two stomas (ileostomy and colostomy). Both periostomal biopsies were positive for B cell lymphoma. Periostomal lymphoma has been rarely reported. Parnesh et al (Case 1) reported a similar case of stomal lymphoma in a patient with history of Ulcerative Colitis. Levecq et al (Case 2) reported a stromal lymphoma in a patient with transfusion related AIDS who underwent total colectomy and ileostomy for indeterminate colitis. The lymphoma was diagnosed at 20 years (Case 1) and 2 years (Case 2) post stoma formation. Lymphoma should be in the differential of stoma being complicated by peristomal tissue proliferation, fistula and infection.
2048 A Rare Manifestation of a Not so Rare Disease
Authors: Elchert Jamie , Ahmad Dina , Sinh Preetika
Published: October 2019

INTRODUCTION:

Pyostomatitis vegetans (PV) is a rare mucocutaneous disease characterized by miliary pustules and ulcerations affecting mucous membranes. PV is classified as a subtype of pyoderma gangrenosum, which affects oral mucosa. The majority of PV cases are associated with inflammatory bowel disease. We present an interesting and a rare case of PV associated with ulcerative colitis (UC) that was successfully treated with infliximab.

CASE DESCRIPTION/METHODS:

A 60-year-old female with history of ulcerative proctitis who had been off therapy for one year presented with abdominal pain, bloody diarrhea, painful oral ulcers, and a 25-pound weight loss over one month. She first noticed the oral ulcers two weeks prior to presentation, and they worsened to a point that she could not eat. Physical examination revealed confluent ulcerations of the buccal mucosa and diffuse abdominal tenderness. Blood work showed hemoglobin of 8 gm/dl, albumin of 2.5 gm/dl, ESR of 101 mm/hr, and CRP of 17 mg/L. C diff was negative. Oral lesions were negative for HSV-1 and HSV-2 by PCR. CT-abdomen showed findings consistent with active left sided colitis. The patient was started on PO and rectal mesalamine and IV methylprednisolone. Colonoscopy revealed severe deep ulcers extending from anus to proximal sigmoid colon with spontaneous bleeding and complete loss of vascular pattern (Figure 1a). During EGD large confluent ulcerations on bilateral buccal mucosa were visualized (Figure 2a–c). Biopsy of the oral lesions revealed ulcerated squamous mucosa and underlying skeletal muscle with mixed, predominantly chronic inflammation. Immunostains for HSV and CMV were negative. Due to minimal response to IV steroids, patient was started on infliximab 10 mg/kg, resulting in dramatic improvement of oral lesions and GI symptoms. Azathioprine was added for dual therapy for the first year. Endoscopic and clinical remission of colitis was achieved (Figure 1b) in addition to complete resolution of PV (Figure 2d). Patient continues to be in remission on infliximab monotherapy two years from initial presentation.

DISCUSSION:

To the best of our knowledge, this is the second reported case of UC with PV successfully treated with infliximab. Our unique case demonstrates a rare extraintestinal manifestation of UC, namely PV, that highlights the importance of early and aggressive anti-TNFα therapy to achieve remission of PV and colitis.
2049 Do UC a Flare in the Bronchus
Authors: Deng Nanfu , Bernica Jessica , Balakrishnan Maya
Published: October 2019

INTRODUCTION:

Inflammatory bowel disease (IBD), which includes Crohn’s disease (CD) and ulcerative colitis (UC), is a GI inflammatory condition that can also affect other organ systems. We highlight a case of IBD-associated lung disease, an established but rarely recognized extraintestinal manifestation of IBD in patients who present with IBD flare and pulmonary symptoms.

CASE DESCRIPTION/METHODS:

A 44-year-old man with untreated UC complicated by pyoderma gangrenosum presented with a weeping leg wound, bloody diarrhea, persistent dry cough, and dyspnea. Prior workup of his cough included CT thorax showing cavitary saccular bronchiectasis, bronchoscopy revealing airway nodules and adhesions, and negative lavage cultures. This time, he presented with worsening pulmonary symptoms characterized by tachypnea and prominent wheezing along with leukocytosis and elevated inflammatory markers. CT thorax showed worsening central bronchiectasis. Due to concern for a lung infection, the patient was started on empiric antibiotics which were later de-escalated after negative cultures. Given suspicion that the bronchiectasis may be related to his current IBD flare, he was started on IV Solumedrol with rapid improvement of respiratory symptoms and transitioned to Infliximab with improvement in his intestinal, pulmonary, and skin manifestations.

DISCUSSION:

IBD is an inflammatory process of the GI tract with a constellation of extraintestinal manifestations. One of the overlooked extraintestinal sites is the lung, which can involve the airway, interstitium, and pulmonary vasculature, with 40-60% affecting the large airways such as in bronchiectasis. IBD-associated lung disease is more prevalent among patients with UC than those with CD. Nearly 25% of IBD patients have abnormal pulmonary function tests (PFTs) or high-resolution CTs, but most remain asymptomatic. Typically, lung disease develops months to decades after GI symptoms but can also precede the diagnosis of IBD. The common embryonic origin of the GI and respiratory tracts from primitive foregut as well as mucosal associated lymphoid tissue in both organs may explain the concurrent inflammatory response. Infection must be ruled out in IBD-associated lung disease as treatment involves immunosuppression, often initially with systemic steroids with case reports also suggesting efficacy of biologics such as Infliximab. Given potential management implications, this case illustrates the importance of recognizing bronchiectasis as an extraintestinal manifestation of IBD.
2054 Crohn’s Colitis Creeping Into a Colonic Conduit
Authors: Reddy Kavya , Al-Taee Ahmad M. , Lee Preston , Schroeder Katie
Published: October 2019

INTRODUCTION:

Crohn’s disease is an inflammatory bowel disease (IBD) that can affect any part of the digestive tract and may present with diarrhea, abdominal pain, and/or weight loss. A subset of patients with Crohn's disease are asymptomatic and are diagnosed endoscopically before the onset of symptoms. Here, we report an unusual presentation of Crohn’s disease which was diagnosed following postoperative complications from a sleeve gastrectomy.

CASE DESCRIPTION/METHODS:

A 46-year-old obese but otherwise healthy female underwent an elective laparoscopic sleeve gastrectomy for weight loss. She had an uneventful perioperative course, however returned one week post op with severe abdominal pain and was found to have staple line dehiscence, esophageal leak and mediastinal fistula requiring multiple repairs, including a failed roux-en-Y esophagojejunostomy and eventually required gastrectomy with esophageal stump. She was transferred to our facility for surgical consultation and underwent right thoracotomy for persistent esophageal leak requiring esophagostomy revision and creation of a spit fistula. Given esophageal discontinuity, a reconstruction with colonic interposition was suggested. In preparation, the patient underwent a colonoscopy with surprising findings of cecal, proximal ascending, and distal sigmoid colonic inflammation [Figure 1]. Biopsies revealed chronic active colitis with cryptitis, suggestive of Crohn’s disease. She denied any symptoms preoperatively and has no family history of IBD. Labs showed elevated calprotectin at 222 ug/g and mild leukocytosis. Magnetic resonance enterography was unremarkable. She was started on Infliximab 5 mg/kg at 0, 2, 6, then every 8 weeks with normalization of calprotectin after 3 doses. She eventually underwent takedown of her spit fistula and jejunal interposition to re-establish esophageal continuity [Figure 2].

DISCUSSION:

This case raises the question of whether the postoperative complication was caused by underlying upper gastrointestinal tract Crohn’s disease. Conversely, it is possible the patient’s numerous gastrointestinal procedures triggered colonic mucosal disease in this susceptible individual. Although this presentation is rare, if similar presentations occur in the future, we may need to consider a role for either preoperative endoscopy or screening with inflammatory markers prior to elective bariatric procedures as this diagnosis could have potentially harmful consequences in the post-operative period.
2061 Treatment of Checkpoint-inhibitor Induced Colitis Leading to Worsening of Melanoma
Authors: Pasha Syed Bilal , Tahan Veysel , Hilli Jaffar , Yezaz Ghouri
Published: October 2019

INTRODUCTION:

Checkpoint inhibitors are monoclonal antibodies directed against checkpoints of immune system such as CTLA-4 receptor and PD-1. They activate the immune system to target melanoma cancer cells but sometimes lead to immune-mediated disorders, including a form of inflammatory bowel disease. In almost 40% of the cases it is refractory to traditional corticosteroid therapy. Treatment with TNF-alpha inhibitors has shown to be successful but thy cause dampening of the immune system. There has been a theoretical concern for progression of the primary cancer, since it counteracts the effects of the check point inhibitors.

CASE DESCRIPTION/METHODS:

We present a case of a 57-year-old male with stage IV melanoma with metastases to lung and sacrum. He was initially treated with ipilimumab and developed mild diarrhea which improved with Imodium. He underwent sterotactic radiosurgery to lung and sacrum, and developed left-sided colitis subsequently complicated with microperforation and abscess formation which was treated with drainage and antibiotic therapy. Ipilumumab was stopped with improvement of diarrhea and then switched to nivolumab. He again developed persistent diarrhea for which he underwent colonoscopy that revealed several ulcers in left colon with pseudopolyps (Figure 1). Biopsy showed crypt architectural distortion with active colitis. He was started on prednisone with improvement of symptoms. He was then started on hydroxchloroquine for immune-therapy induced arthropathy. His diarrhea and joint pain worsened on nivolumab which was stopped and started on Infliximab with improvement of symptoms. His melanoma was stable and the nivolumab was discontinued after 58 infusions. His symptoms further improved, the dose of infliximab was optimized based on trough levels. Subsequently he was found to have recurrence of his melanoma and the infliximab was discontinued which caused recurrence of his diarrhea and arthropathy. He was started on combination of nivolumab with pembrolizumab to treat melanoma.

DISCUSSION:

Our case serves to illustrate a cautious use of infliximab in individuals with melanoma and serves as a recommendation for exploring alternate treatment options such as mesalamine and vedolizumab, which may not have the same potential for interference with checkpoint inhibitors. Use of steroids and budesonide can be a sometimes an alternate strategy for temporary control of disease until the checkpoint-inhibitors are administered.
2068 Acute Febrile Neutrophilic Dermatosis (Sweet Syndrome)
Authors: Shahnawaz Afeefa , Saleem Sheikh A. , Sapkota Bishnu
Published: October 2019

INTRODUCTION:

Sweet syndrome is associated with various GI conditions such as acute gastroenteritis, inflammatory bowel disease and colon cancer. We describe a unique case of a young patient with Crohn’s disease who developed Sweet syndrome while being on infliximab therapy.

CASE DESCRIPTION/METHODS:

A 29 yo M with history of sacroiliitis and fistulizing ileocolonic Crohn's disease on maintenance oral mesalamine and IV infliximab presented with sudden onset of painful papulonodular rash along with high grade fever. The rash involved his face, trunk and upper extremities. He had significant leukocytosis with predominant neutrophilia, elevated ESR and CRP. Infliximab antibody was negative. Skin biopsy showed a dense neutrophilic infiltrate without evidence of vasculitis. Work up for an occult malignancy including a peripheral blood smear, recent colonoscopy and CT scan of the body was unremarkable. Based on the overall presentation he was diagnosed with Sweet syndrome and started on oral prednisone 1 mg/kg body weight daily. Patient showed a rapid response to steroid treatment and the rash completely resolved within a couple of weeks. Differential for his presentation included infliximab induced pustular psoriasis but the biopsy findings were not typical for the condition and there was no recurrence of the rash on continuation of IV infliximab.

DISCUSSION:

Sweet syndrome is characterized sudden onset of papulonodular skin rash and fever. It is of three types; classical, malignancy associated and drug induced. All types can be encountered in the gastroenterology practice and it is therefore important to have good understanding of the condition. Classical sweet syndrome can be seen in patients with inflammatory bowel disease and acute gastroenteritis. Among solid tumor cancers, sweet syndrome can be seen with colon cancer where as various medications prescribed in the GI practice including azathioprine, norfloxacin and furosemide can cause it too. In the appropriate setting a skin biopsy showing dense neutrophilic infiltrate without leukocytoclastic vasculitis can be pathognomonic. Patients usually have an excellent response to systemic steroids. In recalcitrant cases, other immunosuppressive medications such as methotrexate, adalimumab and infliximab have been used successfully. Our case presentation is unique since patient developed Sweet syndrome while being on IV infliximab therapy. In patients with recurrent Sweet syndrome malignancy should strongly be considered.
2072 The Efficacy of Self-Administered Home Fecal Transplant in Inducing and Maintaining Remission in Crohn's Pan-Colitis With Perianal Fistulae
Authors: Almoghrabi Anas , Mbachi Chimezie , Flores Estefania , Demetria Melchor V. , Attar Bashar M.
Published: October 2019

INTRODUCTION:

Fecal microbiota transplantation for treatment of IBD is an off-label use since it has not been approved for the FDA. But its use has been approved as one of the treatment options in recurrent C. difficile infection. The efficacy of self-administered home fecal transplant has not been studied in patients with Crohn's disease.

CASE DESCRIPTION/METHODS:

A 46-year-old woman with history of Crohn’s pancolitis with perianal fistulae diagnosed when she presented with chronic bloody diarrhea, her colonoscopy showed severe colitis characterized by deep ulcers throughout the colon (Figure a-b). Biopsies showed cryptitis and crypt abscesses. She was started on prednisone and azathioprine. She refused biologic treatments because of concerns about side effects. During this time, she developed frequent upper respiratory infections so she self-stopped azathioprine. She initiated a series of self-administered home fecal transplants and continued to do them when she began to feel symptomatic again. She presented to our GI clinic four years later. She denied any abdominal pain, diarrhea, melena, hematochezia, or weight loss. On physical examination her vitals were within normal limits, her abdomen was soft and non-tender. On anal exam, few skin tags were observed, no fistulae. Laboratories were within normal limits, including C-reactive protein. Repeat colonoscopy showed normal terminal ileum, multiple pseudopolyps throughout the colon (Figures 1–4). Random colon biopsies showed quiescent disease.

DISCUSSION:

There is some evidence that suggests changes in the gut microbiota in patients with IBD. These changes over-activate the mucosa immune system leading to chronic inflammation and mucosal lesions. A substantial proportion of patients do not respond to the currently available drugs, most of them immunosuppressive therapy with potential long-term consequences. Consequently, alternative safer therapies are being studied, such as fecal microbiota transplantation. Despite all the studies and investigation in this regard, the FDA only allows the use of FMT for recurrent C. difficile but has tighter restrictions for IBD. In this scenery, those patients can only get a fecal transplant in a medical setting if they are participating in a clinical trial. A handful of case reports have shown the effectiveness of self-administered home fecal transplant in recurrent C. difficile, and the efficacy of FMT, under monitored environment, in refractory CD unresponsive to current conventional therapy.
2082 A Rare Cause of Dyspnea in a Patient With Inflammatory Bowel Disease
Authors: Sobecki Jeffrey , Patel Kruti , Minaudo Mark
Published: October 2019

INTRODUCTION:

5-aminosalicylic acid (5-ASA) and its derivatives are recommended for treatment of mild to moderate Ulcerative Colitis (UC). There have been documented reports of pulmonary toxicity with sulfasalazine, but few reported lung toxicities seen with 5-ASA components alone such as Mesalamine.1

CASE DESCRIPTION/METHODS:

68-year-old female with history of UC on Balsalazide, presented with several months of intermittent, non-radiating chest pain, orthopnea and dyspnea on exertion worsening over 4 days. 98.9 F, HR 115, BP 153/84, RR 22, SpO2 88% on room air improving to 93% with 3 L nasal cannula. Physical exam revealed bibasilar crackles. EKG and CXR were unremarkable. Extensive labs and cardiac evaluation were unremarkable. PFT had decreased DLCO 51% and BAL demonstrated lymphocytosis, moderate eosinophilia with plasma cells. HRCT showed upper lung predominant ill-defined ground-glass opacities, mild bronchial wall thickening and mosaicism. Infectious, hypersensitivity pneumonitis and rheumatologic workup was negative. She did not have worsening of her UC symptoms; CRP 7.86 mg/L (0.00-3.00 mg/L) and Fecal Calprotectin 153 ug/mg (50-200 ug/mg) were noted on admission. Interestingly, Balsalizide was started 8 weeks prior to the patient’s symptoms. With HRCT and otherwise negative lab findings, Balsalizide Induced Pneumonitis (BIP) was suspected. Balsalazide was discontinued, and steroid taper started with resolution of symptoms.

DISCUSSION:

Drug-induced pneumonitis (DIP) and lung toxicities from Sulfasalazine are well documented but few cases of 5-ASA derivatives have been reported. Only four case reports of DIP secondary to Mesalamine have been reported and none with Balsalazide. Diagnosis of pneumonitis is difficult in the setting of IBD due to extensive pulmonary manifestations in IBD ranging from bronchitis to pulmonary fibrosis even when IBD activity is quiessent.1These pulmonary complications typically respond well to steroids alone while DIP responds well to removal of the inciting agent.1 Our patient had an extensive work-up that was negative while the combination of the HRCT and BAL made BIP the leading diagnosis, meeting diagnostic criteria.2 The time frame of the patient’s symptoms in relation to starting Balsalazide supported the diagnosis of BIP and strengthened when Balsalazide was discontinued and prednisone started leading to improvement in symptoms.This patient illustrates the need to consider a broad differential when evaluation a patient with IBD with pulmonary complications.
2083 Mesalamine-Induced Myocarditis
Authors: Putnam Tyler , Turse Erica , Kadkhodayan Kambiz
Published: October 2019

INTRODUCTION:

Mesalamine is a widely used medication for treatment in patients with ulcerative colitis (UC). A rare adverse effect (AE) is mesalamine-induced myocarditis (MIM). A high index of suspicion is essential for prompt diagnosis and prevention of significant morbidity. We present a patient with UC with MIM diagnosis leading to a positive outcome.

CASE DESCRIPTION/METHODS:

31-year-old female with UC presented to the emergency department (ED) with a one-week history of progressive, non-exertional CP. The patient had been on prednisone and mesalamine for two weeks for pan-colitis. Labs revealed troponin 6.085 ng/ml, BNP 1,371.7 pg/ml, ESR 73 mmHg/hr, and C-reactive protein 246.4 mg/dl. EKG, Transthoracic echocardiogram, CT angiography of the chest, and left heart catheterization were inconclusive. Due to the ongoing atypical chest pain, lack of cardiac risk factors, patient's age, and elevated inflammatory markers, a cardiac MRI (CMRI) was ordered and was consistent with myocarditis (Figures 1 and 2). Mesalamine was discontinued with complete resolution of CP and normal troponin. The patient was discharged on colonic release budesonide and two weeks later reported no CP. Labs at that time revealed a negative troponin, low CRP 34, and a BNP of 36.7.

DISCUSSION:

Mesalamine is an effective treatment in UC. Rare AE include blood dyscresias, pleuritis, myocarditis and pancreatitis6. Of these, MIM can be fatal and a high degree of clinical suspicion is required for early diagnosis and management. The pathophysiology of myocardial inflammation with mesalamine remains unclear. A commonly accepted hypothesis is a multisystem cell mediated hypersensitivity type reaction resulting in hypereosinophilia and inflammation4. MIM usually occurs within 2-4 weeks of starting therapy and early diagnosis tends to result in near complete resolution of symptoms after discontinuation of the medication2-5,7. This highlights the importance of prompt diagnosis and management of MIM.
2084 An Atypical Case of Oral Crohn’s Disease
Authors: Marino Danielle E. , Pope-Collins Elizabeth
Published: October 2019

INTRODUCTION:

Oral manifestations of Crohn’s disease are wide-ranging from fissuring and linear ulcerations to cobblestone plaques, mucosal tags, and buccal edema. The commonality between them is the presence of subepithelial non-caseating granulomas on biopsy not explained by another etiology. There is general agreement that oral manifestations are underdiagnosed and that there may be a wider spectrum of disease than previously realized. We present a case of oral Crohn’s that differs in presentation from others previously described in the literature.

CASE DESCRIPTION/METHODS:

25-year-old woman who was diagnosed with Crohn’s ileocolitis on colonoscopy in 2011. After initial treatment failure with mesalamine, she was on Infliximab for 3-4 years but stopped as she preferred to avoid infusions. She started Humira in January 2017 after a Crohn’s flare but did not improve despite the addition of 6-MP. She stopped both Adalimumab and 6-MP in September 2017 after developing facial and lip swelling concerning for an allergic reaction. Complement and C1 esterase inhibitor levels were within normal limits, ruling out hereditary angioedema. Her abdominal symptoms worsened off treatment; colonoscopy revealed moderately active left-sided colitis. While her facial swelling improved, her lip swelling did not. On exam she initially had cobblestoning, a tongue fissure, and swelling of the lower lip. She was evaluated by oral and maxillofacial surgery (OMFS) in May 2018 and at that time had a firm, mobile 1.5 × 1 cm exophytic lesion with surface ulcerations of the right buccal mucosa and right lower lip swelling. The buccal lesion was thought to be either a traumatic fibroma or oral Crohn’s disease. It was excised a month later and pathology revealed granulomatous inflammation with no organisms on gram stain or AFB stain, consistent with oral Crohn’s disease. She subsequently started Ustekinumab and attained clinical and endoscopic remission. An oral prednisone taper for her lip swelling had no effect. She then had 2 triamcinolone injections by OMFS with improvement in the lip appearance.

DISCUSSION:

In this case a woman with intestinal Crohn’s disease developed an exophytic lesion of the buccal mucosa diagnosed as oral Crohn’s disease on biopsy. This atypical presentation of an underdiagnosed aspect of Crohn’s disease points to a wider spectrum of the disease than previously acknowledged. It also highlights the importance of an interdisciplinary approach with dentistry to better recognize and treat oral symptoms.
2085 Suspected Crohn’s in Acute Salmonella Enterocolitis: A Journey of Differentiating Two Common Terminal Ileitis Etiologies
Authors: Kim Alex , Noverati Nicholas , Feldman Andrew , Akhtar Nabeel , Duca Nicholas
Published: October 2019

INTRODUCTION:

Terminal ileitis signifies a generalized inflammatory process in the most distal portion of the small bowel, with an expansive range of underlying etiologies including Crohn’s disease and salmonella. Although stool cultures may reveal a salmonella infection, the diagnosis becomes more difficult if stool cultures are positive but patients do not respond to antibiotics. Treating such pathology with two potential underlying etiologies may lead to further complications, specifically, when administering corticosteroids and immunotherapy for an autoimmune disorder may conflict with active treatment against an acute infection. Our case presents a patient who had known salmonella positive stool cultures but inconsistent colonoscopy and pathology results. He ultimately improved with steroid and anti-TNF therapy.

CASE DESCRIPTION/METHODS:

A 29-year-old male with history of small bowel obstruction of unclear etiology five months prior, presented with acute on chronic diarrhea and abdominal pain. He denied any recent sick contacts, ingestion of raw or undercooked food, or personal or family history of inflammatory bowel disease (IBD). A CT scan identified terminal ileitis. Stool cultures returned positive for salmonella. Despite treatment with ciprofloxacin, patient’s symptoms persisted. Colonoscopy revealed diffuse inflammation and ulceration of the terminal ileum without stricture, with extension into the ascending and transverse colon. Preliminary biopsy revealed reduction in goblet cells. The patient was treated with solumedrol and subsequent infliximab due to the high suspicion of underlying IBD pathology after receiving a course of antibiotics. Though his hospital course was complicated by partial small bowel obstruction, his symptoms ultimately resolved.

DISCUSSION:

Terminal ileitis secondary to Crohn’s disease and salmonella may overlap in presentation which can complicate therapy. In this case, it is probable that there was a component of IBD superimposed with a bacterial infection, given the acute on chronic nature of his symptoms. In the case of superimposed infection, antibiotics should be initiated prior to prescribing immunosuppressive therapy that could allow further invasion. However, waiting to initiate immunosuppressants must be balanced with a patient’s worsening clinical picture and complications such as small bowel obstruction.
2086 The Importance of Careful Appendiceal Inspection During Surveillance Colonoscopy in IBD Patients: A Case of Appendiceal Mucocele in an Ulcerative Colitis Patient
Authors: Horrigan Jamie , Leong Karissa , Calderone Jessica , Aldyab Mahmoud , Valerian Brian , Tadros Micheal , Casale Charles
Published: October 2019

INTRODUCTION:

Appendiceal mucocele (AM) is a rare condition in which the appendix dilates and fills with mucus. These lesions can be benign or malignant and are classified into mucinous adenomas, low-grade appendiceal mucinous neoplasm (LAMN) and mucinous adenocarcinoma. Patients with inflammatory bowel disease (IBD) are at increased risk of colorectal neoplasia, but it is unknown whether IBD is associated with AM.

CASE DESCRIPTION/METHODS:

The patient is a 42-year-old female with a 24 year history of ulcerative colitis (UC) who presented with acute bloody diarrhea. She was diagnosed with UC at age 18, requiring treatment with cyclosporine and prednisone. She maintained steroid-free remission on mesalamine for 20 years before stopping treatment. She was clinically asymptomatic for 4 years until this acute flare. Colonoscopy revealed moderate to severe pancolitis with continuous and circumferential inflammation from the anus to cecum. A 2 cm × 1 cm submucosal mass was found within the appendix, concerning for AM or carcinoid tumor. CT showed appendiceal distention measuring up to 13 mm with a mucocele favored over chronic appendicitis due to the lack of periappendiceal edema. She was started on prednisone and mesalamine to improve the inflammation of the colon and decrease the risk of staple line dehiscence after surgery. Nearly 3 months later, the patient underwent an uncomplicated laparoscopic resection of the appendix and a partial cecectomy. Pathology revealed LAMN with negative margins.

DISCUSSION:

There is a low prevalence of primary appendiceal neoplasms and few reported cases of AM in IBD patients, the majority of which occurring in UC patients. Nevertheless, endoscopists should still be aware of the possible association between IBD and AM due to AM’s malignant potential. This abnormality can be subtle, so careful inspection of the appendix is warranted during routine colonoscopy. Rupture is a dangerous complication as intraperitoneal spread of malignant cells may lead to pseudomyxoma peritonei. Patients may present with right lower quadrant pain, abdominal mass, gastrointestinal bleeding, nausea, vomiting, weight loss and/or intussusception. Patients may also be asymptomatic with a bulging appendix incidentally found on colonoscopy. Diagnosis is further supported by CT or endoscopic ultrasound. Management is appendectomy with possible partial cecectomy or right hemicolectomy depending on tumor size, lymph node involvement, degree of atypia and IBD disease activity.
2087 Severe CMV Proctitis as the Initial Presentation of Ulcerative Proctitis
Authors: Arfeen Mohammad , Scott Brandon , Yarbrough Alex
Published: October 2019

INTRODUCTION:

CMV colitis is seen in patients with IBD on long term immunosuppressive therapy; studies show the rate of seropositivity in IBD patients is the same as the general population (∼70%). Due to this there is a concern for reactivation when long term immunosuppressive therapy is initiated. Here we present the case of a patient who presented with CMV colitis prior to initiation of any therapy or diagnosis of IBD; CMV colitis in immunocompetent patients remains fairly rare.

CASE DESCRIPTION/METHODS:

A 30-year-old male with a history of EoE and PUD presented with seven days of painful hematochezia and constipation; he denied any fevers, however did have chills and cold sweats. He had no history of IVDA, intranasal drug use, anal sex, or risky sexual behaviors. His EoE symptoms were well controlled on PPI. Temperature was 103.2 F, he was tachycardic and tachypneic on presentation. CT revealed fecalization of the small bowel, significant stool burden, and rectal stool ball. He was started on lubiprostone and a bowel regimen with PEG-3350, he passed stool with significant decrease in abdominal distention, however he continued to have rectal pain and hematochezia. Colonoscopy was performed and showed diffuse severe inflammation with erythematous, granular, and friable mucosa in the rectum. He was started on rectal mesalamine and corticosteroid therapy. Biopsies returned showing CMV associated severe ulcerative proctitis without evidence of dysplasia. He was then started on ganciclovir and PICC was placed for 2 weeks of treatment. Repeat HIV and HIV viral load testing were done, both returning negative. On follow up in clinic he reported good control of his symptoms with oral and rectal mesalamine. Flexible sigmoidoscopy showed a rectal scar and significantly improved inflammation, biopsy revealed ulcerative proctitis.

DISCUSSION:

CMV colitis has been commonly associated with UC patients on immunosuppressive therapy. An increasing body of literature shows the presence of colonic CMV infection in patients with UC on therapy has been associated with decreased response to steroids and other immunosuppressive therapies. Prognosis is poor unless the infection is promptly identified and anti-viral therapy is started. It still remains a rare entity in immunocompetent patients. This raises the question if CMV testing should be done prior to initiation of immunosuppressive therapy in these patients and if CMV testing should be done regularly in patients with refractive UC flares.
2088 A Rare Case of Postoperative Recurrence of Crohn’s Disease Associated With Abdominal Actinomyces and Bacteremia
Authors: Khanna Tushar , Vielemeyer Ole , Rubin Moshe , Scherl Ellen J.
Published: October 2019

INTRODUCTION:

We present a rare case of actinomyces bacteremia in a 27-year-old woman with fistulizing Crohn's ileocolitis who presented with acute abdominal pain in the setting of sepsis & microperforations 6 weeks after extensive bowel surgery.

CASE DESCRIPTION/METHODS:

The patient's Crohn's disease was diagnosed 10 years ago, treated initially with 6-MP, azathioprine, 5-ASA & later with biologics & steroids all of which provided minimal relief. Prior to undergoing surgery, she had daily complaints of RLQ abdominal pain with MRI suggestive of significant ileocolitis with fistulae. She underwent successful ileocolectomy & fistula stricturoplasties with remarkable improvement in symptoms in the 3 weeks post-op. However, 6 weeks post-op her condition worsened again with new onset of pain, fever, tachycardia, hypotension and imaging concerning for perforated bowel. She was thus readmitted with admission blood cultures revealing Actinomyces odontolyticus bacteremia. Abdominal CT showed possible small perivesicular fluid collection. Repeat blood cultures on antibiotics remained sterile & the patient was discharged on antibiotics. Local anaerobic cultures from the neo-terminal ileum on repeat colonoscopy with biopsy 6 weeks post-op were also found to be sterile, with no evidence of actinomyces on pathology indicating possible clearance of local infection on antibiotics.

DISCUSSION:

We describe an unusual complication of Crohn’s disease: abdominal Actinomyces infection presenting with bacteremia. Actinomyces spp. are anaerobic gram-positive bacilli, most commonly found as part of normal flora of the oral cavity; it can also colonize the pharynx, other parts of the GI tract, GU system and the skin. It becomes virulent if introduced into deeper tissues through disruption of mucosal surfaces. Actinomyces often mimics other intra-abdominal conditions such as Crohn’s through the formation of fistulas & sinus tracts. The patient’s postoperative Crohn’s recurrence at the neo-terminal ileum confirmed on imaging paired with positive blood cultures in the setting of sepsis, raises a strong suspicion of infection due to Actinomyces spp. as the cause for worsening Crohn’s disease. This case suggests that abdominal actinomyces infection can be an unusual complication of Crohn’s disease and presents a diagnostic dilemma for clinicians given overlapping clinical & imaging findings. Gram stain and anaerobic culture remain the gold standard for the diagnosis of actinomyces & penicillin is usually the treatment of choice.
2089 Psoriasis Induced by Infliximab Treatment in a Young Patient With Crohn’s Disease
Authors: Shahid Rizwan , Singhania Rohit , Gupta Kamesh , Knox Spencer C.
Published: October 2019

INTRODUCTION:

Now that Infliximab has been used more frequently for treatment of multiple autoimmune diseases including IBD, side effect profile of infliximab has increasingly been seen in clinical practice. One of the rare side effect is induction of psoriasis with infliximab though paradoxically it has been used as a treatment in psoriasis. We present a case of young female with Crohn’s who developed palmoplantar psoriasis while on infliximab.

CASE DESCRIPTION/METHODS:

30 Y/O female with history of Crohn’s s/p ileocecectomy (diagnosed in 2016 and subsequently lost to follow up), presented to GI clinic for ongoing diarrhea and abdominal pain for 2 months. She underwent elective colonoscopy which showed typical Crohn's appearance with endoscopic Rutgeerts Score of I3. She was started on infliximab and azathioprine after pretreatment testing. Three months into the treatment, she developed a new papular rash limited to her palms and soles which progressed to dry, erythematous rash with sloughing. She was diagnosed of drug induced psoriasis by dermatology and was started on topical petroleum based therapies and oral steroids. She showed no improvement in next few weeks and in fact, developed a new scalp rash. At this point, decision was made to stop Infliximab and start her on Stelara. Her rash started improving significantly after making this change and her bowel symptoms continued to be well controlled as well.

DISCUSSION:

TNF alpha inhibitors are currently the mainstay therapy for treatment of moderate to severe Crohn’s disease. TNF-a induced psoriasis is a major challenge for treating clinician. Prevalence of Psoriasiform lesions range from 1.7 to 35% in different studies. Its mechanism of action is unclear but it could be due to unopposed production of Interferon-A caused by TNF-a inhibitors as IFN-a is a well known trigger for development of psoriasiform lesions. First step in management includes topical therapies and oral steroids directed at controlling skin disease. If this fails, some studies suggest use of another TNF-a inhibitor though there is cross reactivity among different members of the class. Availability of Interleukin 12/23 inhibitors like Ustekinumab (Stelara) is an excellent alternative for such Crohn’s patients as it is also approved for psoriasis. We used this strategy in our patient who showed clinical improvement very quickly. There is certainly need of further analysis and studies to understand long term consequences of this approach as experience is still insufficient on this.
2092 A Rare Case of Primary Colonic Lymphoma Mimicking Metastatic Adenocarcinoma in a Patient With Ulcerative Colitis
Authors: Mavuram Meher S. , Maruvada Smita , Rashid Shazia , Hafiz Nazar , Chaudoir Catherine , Saire mendoza Mardeli , Samant Hrishikesh , Morris James D.
Published: October 2019

INTRODUCTION:

Primary colorectal lymphoma (PCL) is uncommon and accounts for only 0.2-1% of all large intestine cancers. There is an increasing incidence in populations with Inflammatory bowel disease (IBD), Celiac disease, H. pylori and other autoimmune conditions. Here, we present a rare case of Ulcerative Colitis with primary Diffuse Large B Cell lymphoma (DLBCL) and liver metastasis.

CASE DESCRIPTION/METHODS:

Our patient is a 50 y/o male with left-sided ulcerative colitis presenting with a two- month history of severe left lower quadrant abdominal pain and constipation, without overt GI bleeding, diarrhea or weight loss. Examination was remarkable for left lower quadrant tenderness, without palpable mass. CT scan revealed multiple ill-defined liver masses concerning for metastasis with circumferential thickening in sigmoid colon with fat infiltration. Of note, patient had surveillance colonoscopy, few months prior to presentation which revealed marked erythema in the sigmoid colon, biopsies revealed acute on chronic inflammation without evidence of malignancy. Labs with normal CEA, AFP, CA 19- 9 levels. Repeat colonoscopy showed an ulcerated stricture with friable nodular mucosa in the sigmoid colon that was again biopsied in conjunction with biopsy of the liver lesions. Immunohistochemical staining of colon and liver lesions was positive for CD20 and negative for CK20, CK7 and CDX2, consistent with DLBCL. Patient was started on R-CHOP chemotherapy and is currently being monitored for response by Oncology.

DISCUSSION:

The risk of colorectal cancer significantly increases in IBD and surveillance is usually warranted. Although the suspicion of adenocarcinoma remains high in a UC patient with colonic mass and liver metastasis, PCL should also remain in the differential as correct pre-operative identification is crucial for the design of treatment. PCL is rare, with a male predominance in age 50-70 years and typically present with abdominal pain, lower GI bleeding, weight loss, palpable mass and rarely bowel obstruction. Diagnosis is aided by tissue biopsy and imaging. Multimodality approach involving both surgery and chemotherapy is the principal mode of treatment with radiotherapy in selected cases. Considering our patient’s clinical scenario, further speculations in routine CT scans to evaluate symptoms, alongside endoscopic surveillance for colorectal cancer in IBD, needs to be addressed.
2099 E. coli Sepsis Following FMT in an IgA Deficient IBD Subject
Authors: Glover Sarah C. , Burstiner Shane , Jones Demarre , Teymoorian Arian , Naga Yehia , Silver Jared , Pallav Kumar
Published: October 2019

INTRODUCTION:

Fecal microbiota transplant (FMT) has been demonstrated to be an effective treatment option for recurrent C. difficile infections (RCDI) with minimal serious adverse reactions reported. Although the results of FMT for RCDI are promising, the screening process (for both donors and recipients) remains largely unregulated by the FDA.

CASE DESCRIPTION/METHODS:

A 19 y.o. male with a history of primary IgA deficiency, growth hormone deficiency, asthma, and ulcerative colitis presented to his gastroenterologist with his 3rd C. difficile infection in a 4 month period. FMT was performed via colonoscopy using commercially sourced stool. 10 days later, the patient presented to the ER with explosive bloody diarrhea, up to 20 BMs per day. He was also positive for leukocytopenia, tachycardia, intermittent subjective fevers, chills, night sweats, and abdominal cramping. Stool studies were positive for EPEC, ETEC, and Shiga toxin-producing E. coliO157:H7. Patient was not given antibiotics and received supportive care for 17 days until discharge. He has a good prognosis and has not experienced a recurrence of CDI since the FMT 3 months ago. Unbeknownst to his Gastroenterologist, the patient had a history of mostly asymptomatic, total primary IgA deficiency that was diagnosed in the Czech Republic.

DISCUSSION:

This appears to be the first reported instance of an individual with Primary IgA Deficiency undergoing FMT and also the first reported instance of FMT-introduced E. coli O157:H7 infection. The patient’s complete lack of IgA appears to be the main catalyst for his disastrous response to FMT. While barrier defects secondary to IBD and the concomitant use of immunosuppressive medications (Xeljanz and Entyvio) can increase susceptibility to infections, studies have shown FMT does not carry an increased risk of serious adverse effects in immunocompromised patients (including IBD patients on immunosuppressive therapy). This patient was not screened for immunodeficiencies prior to receiving FMT. The FDA has issued guidelines, but does not currently mandate which pathogens the stool must be screened for, or which comorbidities the recipient must be screened for. Given the understood importance of IgA in mucosal immunity against E. coli, and the outcome presented in this study, we suggest that rigorous screening of the recipient's medical history for immunodeficiency, and/or potentially running a basic Immunoglobulin panel, should be considered prior to performing FMT.