bluuebunny/crossref_metadata_2025 huggingface dataset:
1541 Colorectal Lymphoma: A Wolf in Sheep's Clothing
Authors: John Jason J. , John Elizabeth S. , Linder Jeffrey
Published: October 2019

INTRODUCTION:

Although extranodal lymphomas are most commonly found in the gastrointestinal (GI) tract, colorectal lymphomas are a rare diagnosis accounting for only 0.2% of large intestinal malignancies and 4% of malignancies in the entire GI tract. We report a case of a female patient with vague abdominal symptoms, ultimately diagnosed with diffuse large B-cell lymphoma (DLBCL) of the colon.

CASE DESCRIPTION/METHODS:

A 55 year old African American female with HIV (CD4 164) was admitted for acute shortness of breath and 4 months of intermittent diffuse abdominal pain. She denied any diarrhea, changes in bowel habits, hematochezia, melena, or weight loss. Imaging revealed a pneumonia and nonspecific mesenteric lymphadenopathy (LAD), but no bowel abnormalities. Her abdominal pain initially improved with treatment of the pneumonia, but she was readmitted to the hospital one month later with recurrence of the abdominal pain and worsening shortness of breath. Vitals included BP 136/94, HR 125, RR 25, SpO2 90%, T 98.5. Exam showed bibasilar crackles and accessory muscle use with respirations. She had diffuse abdominal tenderness without obvious hepatosplenomegaly or LAD. Laboratory workup showed WBC 5.2 (normal differential), Hb 11.0, Platelets 361, normal CMP, BNP 300, LDH 9,845. CT revealed new bilateral pleural effusions, nonspecific mesenteric LAD, and mild transverse colon thickening (Figure 1). Colonoscopy revealed a non-obstructive 4 cm mass in the transverse colon. Biopsies revealed high-grade DLBCL. Thoracentesis confirmed the diagnosis. Before treatment could be initiated, the patient expired from tumor lysis syndrome and subsequent cardiac arrest.

DISCUSSION:

Colorectal lymphoma is extremely rare. Early recognition is crucial as stage I and II disease can be treated with surgery and chemotherapy, and if not treated, the mortality rate is 58%. Though DLBCL can occur in 5-10% of patients with HIV, the incidence of GI involvement in this population is still as low as 3%. As with our patient, diagnosis is often delayed due to nonspecific and non-localizing symptoms and signs. Imaging can be helpful, but can have a wide variety of characteristics–bulky masses, diffuse infiltration, multi-site involvement, and lymphadenopathy. Definitive diagnosis relies on histologic analysis. Later diagnosis also limits treatment. Management of stage I and II include chemotherapy and surgery while stage III and IV often require clinical trials. This case presentation highlights the importance of early diagnosis.
1543 Melanoma Coli: A Rare Case of Diffuse Metastatic Melanoma to the Colon Presenting as Diarrhea
Authors: Zhang Daniel S. , Shen Steven , Mathur Neha
Published: October 2019

INTRODUCTION:

An 84-year-old male with history of melanoma of his left ear removed six years ago with clear margins presented to the hospital with a one year history of worsening diarrhea and weight loss, but denied rectal bleeding. Labs showed anemia of chronic disease, elevated inflammatory markers, with infectious and chronic diarrhea workup negative. Upper endoscopy was unremarkable, however colonoscopy showed a large 3 cm fungating, ulcerated, infiltrative mass within the cecum with multiple masses throughout the colon (Figure 1a,b). Biopsies were taken from the multiple masses, which all showed colonic mucosa with infiltrating epithelioid and plasmacytoid cells with frequent mitotic figures (Figure 2c,d). Immunohistochemical staining was positive for melanocytic markers S100, HMB45 and Sox10 consistent with malignant melanoma (Figure 3e–g). Further molecular testing showed positive BRAF and NRAS mutations, which are reported in 13-25% of malignant melanomas.

CASE DESCRIPTION/METHODS:

Metastatic melanoma to the colon is rare due to the absence of melanocytes in the colon apart from the ano-rectal region. More than 95% are diagnosed post-mortem, which is. The average interval between diagnosis of primary melanoma and discovery of colonic involvement is between 5-7 years. The overall incidence of large bowel metastasis is 0.3% with a mean age at diagnosis of 57.8. Hematochezia is the most common symptom, followed by anemia, obstruction and perforation. Primary therapy is based on chemotherapy and immunotherapy, unless surgical intervention is required for obstructive symptoms or perforation. Overall prognosis remains poor with an average survival of 7 months and a 5-year overall survival of 25%.

DISCUSSION:

Here we present a rare case of metastatic melanoma to the colon as a cause of diarrhea and anemia. This should always be considered in any patient with a remote history of melanoma.
1546 Idiopathic Myointimal Hyperplasia of Mesenteric Veins: A Rare Cause of Treatment Refractory Colitis
Authors: Oruganti Poornima , Awan Rehmat Ullah , Sugimoto Matthew , Tey Kai Rou , Nunez-Herrero Laura , Ding Xianzhong , Ma Yihong , Abegunde Ayokunle T.
Published: October 2019

INTRODUCTION:

Idiopathic myointimal hyperplasia of mesenteric veins (IMHMV) is a rare disease which mimics inflammatory bowel disease (IBD) clinically and endoscopically while showing ischemic changes without classic features of IBD on pathology. Delay in diagnosis is common; definitive diagnosis is usually only feasible after surgical resection.

CASE DESCRIPTION/METHODS:

A 62-year-old male with a past medical history of hypertension and hyperlipidemia presented with a 1-year history of recurrent abdominal pain, bloody diarrhea, and rectal pain. He was initially evaluated at another hospital and diagnosed with pneumatosis intestinalis and left-sided colitis. Left colon biopsies were suggestive of ischemia but computerized tomography angiogram (CTA) revealed patent mesenteric arteries. Extensive workup for thrombophilia, infectious, inflammatory, and autoimmune etiologies were negative. His symptoms did not respond to antibiotics and oral steroids. He presented to our institution for a second opinion. At presentation, he was diaphoretic, afebrile and in distress. Physical exam was significant for lower abdominal tenderness without peritoneal signs. Laboratory investigations revealed elevated inflammatory markers (Table 1). Repeat CTA showed patent mesenteric arteries. Colonoscopy revealed severe inflammation and congestion extending from the mid-transverse colon to the rectum. The terminal ileum and ascending colon were normal. Biopsies from inflamed mucosa revealed ischemic colitis with fibrinoid microvascular wall necrosis and fibrin thrombi (Figure 1). He was started on IV Methylprednisolone 40 mg daily but symptoms progressed despite IV steroids. He underwent total colectomy with end ileostomy which was curative. Histopathological analysis of the resected colon confirmed IMHMV.

DISCUSSION:

Current opinion suggests that IMHMV is caused by non-inflammatory, non-thrombotic obliteration of medium-to-large size mesenteric veins. IMHMV is a difficult diagnosis to make preoperatively. However, preoperative diagnosis is suggested by the presence of arterialized capillaries, subendothelial fibrin deposits and fibrin thrombi on endoscopic biopsies. IMHMV is typically refractory to steroids and biologics. Gastroenterologists and pathologists should have a high index of suspicion for IMHMV in patients with treatment refractory colitis, negative mesenteric angiography and colon biopsies showing ischemic changes without classic features of IBD. Colectomy is usually curative without recurrence of symptoms.
1547 Pseudomonas Aeruginosa: A Rare Cause of Community-Acquired Antibiotic-Associated Diarrhea in an Immunocompetent Adult
Authors: Hoff Ryan T. , Patel Ami , Shapiro Alan
Published: October 2019

INTRODUCTION:

Pseudomonas aeruginosa (P. aeruginosa) is an opportunistic gram negative pathogen known to cause enterocolitis in children and nosocomial infections, including hospital acquired pneumonia (HAP) and catheter associated urinary tract infections (UTIs). Rarely, P. aeruginosa causes antibiotic-associated diarrhea in immunocompromised hosts, but this has not been reported in immunocompetent ambulatory hosts.

CASE DESCRIPTION/METHODS:

An 81 year old previously healthy woman presented to the emergency department (ED) with diarrhea for 2 days. A week prior to symptom onset, she completed a 17 day course of ciprofloxacin for a UTI, with resolution of dysuria. She described frequent, watery, nonbloody bowel movements with nausea and emesis. She was treated with intravenous saline and ondansetron, and discharged. The next day, she developed bloody bowel movements associated with weakness and mild lower abdominal pain. With ongoing diarrhea, she returned to the ED. Physical exam showed very mild left lower quadrant abdominal tenderness, without rebound or guarding. Laboratory studies showed white blood cell count 11,800 cells/mcL, potassium 3.3 meq/dL, and lipase 67 units/L. Electrolytes and liver enzymes were otherwise normal. Clostridium difficile (C difficile) stool toxin PCR was negative. CT abdomen and pelvis without contrast showed diverticulosis and mild inflammation surrounding the sigmoid colon (Figures 1 and 2). She was started empirically on ciprofloxacin and metronidazole, and admitted to the medical floor. Over the next 3 days, she gradually improved. Stool culture grew P. aeruginosa, with absence of normal fecal flora. Sensitivities showed resistance to ciprofloxacin and levofloxacin. Given her clinical improvement, antibiotics were discontinued after 7 days.

DISCUSSION:

We report a case of P. aeruginosa as a cause of bacterial colitis. Our patient's prior antibiotic therapy may have increased her susceptibility to this infection via loss of normal fecal microbiota, leading to a loss of competitive exclusion and diminished colonic barrier protection. To our knowledge, this is the first reported case of post-antibiotic diarrhea caused by P. aeruginosa in an immunocompetent ambulatory host. This may be an important diagnostic consideration in patients presenting with persistent diarrhea following antibiotics, with negative C. difficile stool testing. The role for antibiotic therapy in Pseudomonas associated diarrhea warrants further research.
1549 Intermittent Hematochezia Due to Colonic Endometriosis
Authors: Tielleman Thomas J. , Wachsmann Megan B. , Hammer Suntrea , Ahmed Tasneem F.
Published: October 2019

INTRODUCTION:

Endometriosis is a disease defined by the presence of endometrial epithelium implanted outside of the uterus. The prevalence in reproductive age women is 10-15%, with the most common site being the ovaries. However, gastrointestinal involvement of endometriosis has been reported to occur in 3-37% of patients with endometriosis, with the rectosigmoid colon being the most common gastrointestinal site of involvement. The disease is usually diagnosed by imaging and surgical techniques whereas colonoscopy is not typically considered a mode of diagnosis for colonic endometriosis.

CASE DESCRIPTION/METHODS:

A 46 year old female with past medical history significant for OSA on CPAP, Secondary Polycythemia, HTN, HLD, Depression, and history of hysterectomy with tubal ligation 20 years prior presented as a referral for colonoscopy in the setting of intermittent rectal bleeding. She reported a ten month history of monthly episodic pelvic pain and mild rectal bleeding not associated with bowel movements. The timing of the bleeding was similar to her normal menstrual cycle. However, she denied vaginal bleeding and reports that she had a total abdominal hysterectomy 20 years prior due to a “cyst” on her uterus. In the 2 months prior to colonoscopy, the patient also developed some blood coating her stools intermittently during bowel movements as well. On presentation, patient's vital signs were within normal limits. Cardiac and pulmonary examination were normal. Abdomen was soft, non-tender, and non-distended with normal bowel sounds. On colonoscopy, the patient was found to have small non-bleeding external hemorrhoids, a 5 mm tubular adenoma in the transverse colon, and a 13 mm lesion in the recto-sigmoid colon that appeared to be arising from a depression in the mucosa. Initial attempt to lift lesion with 5 cc of Eleview injected into the submucosa was unsuccessful. Ultimately, the lesion was removed with hot snare. Pathology revealed endometriosis involving the mucosa and submucosa.

DISCUSSION:

Endometriosis is an uncommon cause of rectal bleeding. In young female patients of reproductive age, this should be on the differential. Moreover, it is important to keep this in mind in post-menopausal women as well.
1550 Overflow Diarrhea in the Setting of Urinary Retention
Authors: Van Jeremy , Abraham Rana
Published: October 2019

INTRODUCTION:

Overflow or paradoxical diarrhea is the seepage of stool around an intestinal impaction. This is typically described in patients whom have chronic constipation. There have been cases described of bowel compression from malignancy or even urinary retention causing bowel obstruction. To our knowledge, there are no reports of overflow diarrhea in patients with urinary retention which resolved after starting clean intermittent catheterization (CIC) for urinary drainage.

CASE DESCRIPTION/METHODS:

A 43 year old male with past medical history of peptic ulcer disease s/p gastrectomy with Billroth II anastomosis, GERD, Barrett's Esophagus, and Schizoaffective disorder presented with a 2 month history of 15+ loose, watery stools and abdominal pain daily along with a 2 year history of urinary retention. To work up the patient's diarrhea, celiac serologies, c-reactive protein (CRP), stool culture, stool ova and parasite, fecal pancreatic elastase, and CT abdomen/pelvis w/o IV contrast were ordered. CRP and celiac disease serologies were unremarkable and he never completed his outpatient stool studies. CT displayed a severely distended bladder compressing the small and large bowel without distension of bowel loops. He subsequently visited a Urologist and was diagnosed with myogenic bladder failure. After starting CIC, the patient was down from 15+ loose stools to 2-3 semi-solid stools daily and his abdominal pain resolved.

DISCUSSION:

Commonly, there can be extrinsic compression of the bowel from entities such as malignancy and adhesions. Overflow diarrhea is typically seen in patients with constipation. In this patient, he likely experienced multiple loose stools daily from stool seepage past bowel compression created by a distended bladder. No antibiotics were taken prior to his diarrhea occurring and he had no changes in diet. Fecal elastase testing, stool culture, and stool ova and parasites weren't completed, but pancreatic insufficiency and infection were less likely given his improvement with CIC. In patient's whom are having both urinary retention and diarrhea, it is important to rule out overflow as an etiology for diarrhea. This case also highlights the bidirectional relationship between urinary retention and constipation.
1553 A Phantom of the Large Bowel!
Authors: Amarnath Shivantha , Fady Haddad , Deeb Liliane
Published: October 2019

INTRODUCTION:

Giant colonic diverticulum (GCD), referred to as giant colon cyst or “phantom tumor,” is a diverticulum that commonly arises from sigmoid colon and is larger than 4 cm in diameter. This occurs mostly in individuals older than 60 years and its pathogenesis is not well understood. Two theories have been proposed that could co-exist: A one-way valve mechanism at the transition point between the bowel lumen and diverticulum permitting air entry and progressive increase in intraluminal pressure with subsequent enlargement of the diverticulum. Alternatively, gas forming bacteria encased within a cyst of the colon contributing to chronic inflammation and consequent gradual distention of a diverticulum. Patients are mostly asymptomatic, otherwise common clinical manifestations range from a soft palpable abdominal mass to lower abdominal pain, constipation or rectal bleeding. However, it is uncommon for GCD to present as acute diverticulitis, and to our knowledge, this is a rare case to be reported in the literature. Herein we report a case of an elderly male who presented with sepsis due to acute diverticulitis as an initial presentation of a GCD.

CASE DESCRIPTION/METHODS:

A 63-year-old bed-bound male with a history of multiple sclerosis and major depression presented to our hospital with generalized abdominal pain of one-day duration. The patient was febrile at 101 F, and physical exam was remarkable for lower abdominal tenderness without guarding. He was septic with evidence of leukocytosis of 23,400/mm3, neutrophilia and lactate of 3 mmol/L (normal range: 0.5–2.2 mmol/L). A CT of the abdomen with contrast demonstrated an isolated 4.5 cm diverticulum at the sigmoid colon with evidence of acute diverticulitis. There was no evidence of a focal drainable abscess, free air or diverticulosis in other colon segments. He was considered high risk for surgery due to his sedentary status and was conservatively managed with parenteral antibiotics. His symptoms resolved and discharged three days later, without any further complications.

DISCUSSION:

GCD is a rare manifestation of diverticular disease and can present with a myriad of symptoms. Acute diverticulitis should be considered in those with evidence of sepsis and at risk of developing GCD. The gold standard treatment of en-bloc resection of the GCD with primary anastomosis is not always ideal for the management of this entity and a more conservative approach can be taken in high-risk surgical candidates as in our patient and may lead to a favorable outcome.
1558 Diffuse Primary Gastrointestinal Mantle Cell Lymphoma: A Rare Cause of Hematochezia
Authors: Singh Tamneet , Aggarwal Pankaj , Moreau Chris , Dominguez Cristian , Hughston Adam , Sayana Hari
Published: October 2019

INTRODUCTION:

Mantle cell lymphoma (MCL) is non-Hodgkin lymphoma that classically does not involve the gastrointestinal (GI) tract. Although in some cases MCL has been shown to spread to the GI tract, primary gastrointestinal MCL is exceedingly rare and has only been described anecdotally. Often, the diagnosis of MCL is made once the disease is metastatic given its largely nonspecific symptom profile. We present a case of diffuse MCL of the GI tract presenting as hematochezia, in a patient with ulcerative colitis.

CASE DESCRIPTION/METHODS:

An 80-year-old male with history of newly diagnosed ulcerative colitis (UC) presented with four weeks of worsening diarrhea and hematochezia associated with a 30-pound weight loss over five months. He had been on mesalamine for UC, but had not experienced symptomatic relief. On admission, the patient was anemic to a hemoglobin of 9.3 g/dL, white blood cell count of 21.6 × 103/L with 13% bands and 48% atypical lymphocytes, and an albumin of 1.7 g/dL with normal platelets and INR. Abdominal imaging showed diffuse mesenteric lymphadenopathy concerning for a lymphoproliferative process and circumferential gastric, rectal and sigmoid wall thickening and edema. Clostridium Difficile (C. Diff) stool PCR was positive, and he was started on oral vancomycin therapy. Colonoscopy showed diffuse inflammation and edema of the colon with poor mucosal integrity and a hypertrophic mass in the ascending colon. Upper endoscopy showed diffuse, hypertrophied, thickened folds within the stomach and duodenum along with ulcerations. Endoscopic ultrasound was performed to biopsy para-aortic and celiac lymph nodes. Given high suspicion for lymphoma, a bone marrow biopsy was also obtained. Histopathology from the multiple biopsies were all consistent with Stage 4 pleomorphic Mantle Cell Lymphoma.

DISCUSSION:

This case describes a rare presentation of MCL, complicated by C. Diff colitis in addition to UC. There has been little data to show that these unique clinical entities are significantly correlated. Although hematochezia is a rare presentation of MCL, clinicians should maintain a high index of suspicion for malignancy and pursue additional imaging and/or procedures, even in a patient that has other reasons to present with hematochezia. This case of advanced stage MCL of the GI tract adds to a small body of literature regarding primary gastrointestinal MCL and warrants further research in to this rare gastrointestinal malignancy.
1562 Rare Intestinal Spirochetosis Masquerading as a Colonic Polyp
Authors: Pacha Faris , Skrove Jamie L. , Salhab Joseph , Pina Victor M.
Published: October 2019

INTRODUCTION:

Spirochetosis in colonic mucosa is exceedingly rare in non-immunocompromised individuals. There have been less than 200 cases documented and more rare with the specific B. Pilosicoli genus. Spirochetosis is also seen in individuals who engage in high risk sexual encounters. This type of spirochetosis is found mosty in dogs, cats, pigs and chickens. Symptoms in humans include diarrhea, rectal bleeding, and abdominal cramps. Colonic spirochetosis is more common in third world countries. Even in immunocompromised state of health and with all other factors there is much unknown about colonic spirochetosis. Due to its infrequency the treatment is metronidazole and repeat colonoscopy and biopsy should symptoms persist.

CASE DESCRIPTION/METHODS:

Patient is a 62 year old male patient who presented as an outpatient consultation for screening colonoscopy. The patient complains of abdominal pain for several months that is localized in the right upper quadrant. The patient describes the pain as moderate to sharp and only last a few minutes after onset. Patient also reported post prandial fullness, abdominal bloating and distention. The patient denied rectal bleeding, melena, constipation, or pain on evacuation. The patient denies other symptoms. The patient has no medical history and only surgery was an elective laparoscopic cholecystectomy. The Decision was made to undergo screening colonoscopy. The patient had no history of immunocompromised state or HIV/AIDS. The patient denies anal sex. Colonoscopy revealed he had two polyps. One in the ascending colon and the other in the rectum. The specimens were sent for pathology for analysis. Ascending polyp was analyzed and it demonstrated colonic mucosa consistent with intestinal spirochetosis specifically Brachyspira pilosicoli. The rectal polyp was hyperplastic no adenomatous change.

DISCUSSION:

This case was chosen because only 200 known cases of colonic mucosa infected with spirochetosis have been documented. The patient is not immunocompromised, does not engage in anal sex, is not in a third world country, and does not have typical symptomatology of infection with Spirochetosis. In general colonic involvement with spirochetosis is very misunderstood due to its infrequency. The genus of B.pilosicoli. Is a spirochete genus that has limited data on how many cases have been documented. The presentation as a colonic polyp as a masquerade for actice spirochetosis infection prompts further study.
1566 Pylephlebitis and Intestinal Necrosis: An Unexpected Outcome of a Common Infection
Authors: Ilyas Suleman , Gonzalez Manuel O.
Published: October 2019

INTRODUCTION:

Although rare, pylephlebitis should be included on the differential for any patient with CT imaging showing thrombosis in the portal vasculature, with a recent intraabdominal infection. Although there are not yet guidelines for management of this potential deadly complication, patients who received early antibiotics and anticoagulation have been associated with better outcomes.

CASE DESCRIPTION/METHODS:

A 59-year-old female presented with worsening abdominal pain two days after being discharged for uncomplicated diverticulitis, for which she was receiving a course of ciprofloxacin and metronidazole. Initial CBC was significant for a leukocytosis of 19.5 K/uL, and CT imaging revealed an inferior mesenteric vein (IMV) thrombosis extending up to her portal vein. She was continued on her antibiotics and started on unfractionated heparin for systemic anticoagulation. Despite these interventions, the patient continued to experience worsening abdominal pain, with physical exam revealing significant rebound tenderness. Interventional radiology (IR) guided aspiration on hospital day (HD) 6 as well as endoscopic aspiration on HD 9 were attempted. However, the location of the infectious process was prohibitively difficult to access. Repeat CT imaging done on HD 10 showed progressive septic thrombophlebitis with evidence of bowel ischemia. She underwent emergent washout with left colectomy and end colostomy. Throughout her admission, her course had been complicated by perforated diverticulitis and candida dubliniensis fungemia. The patient eventually improved and was discharged on HD 29. She was discharged to complete piperacillin-tazobactam (4 weeks of therapy), anidulafungin (6 weeks of therapy) and Coumadin (6 months of therapy).

DISCUSSION:

Pylephlebitis is a grave condition that can arise from common infections adjacent to the portal venous system. Diagnosis is now commonly made by imaging showing thrombosis in the portal vasculature. The mortality rate is significant, estimated to be 11-25%. Repeat imaging should be considered if there is lack of clinical improvement. Broad spectrum antibiotic therapy is a mainstay of treatment. Lower mortality rates and improved outcomes have been shown in those who were anticoagulated. Complications can be seen in up to 20% of patients, the most common of which are chronic thrombosis or extension of the thrombus, bowel ischemia and abscess formation. Surgery is not required for the initial management but can be used to obtain source control and manage complications.
1572 Strongyloides stercoralis AutoInfection
Authors: Melki Gabriel , Komal Fnu , Laham Linda , Karim Gres , Yuridullah Ruhin , Vora Aarohi , Zoldak Wioletta , Barham Shaker , Botros Youssef , Estifan Elias , Hajjar Bassam , Michael Patrick
Published: October 2019

INTRODUCTION:

Strongyloides stercoralis is an intestinal roundworm that infect humans through contact with soil that is contaminated with free-living larvae. The larvae penetrate the skin and migrate through the body to the small intestine to lay their eggs. It is associated with immigrant populations from tropical regions such as Southeast Asia and the south pacific. Strongyloidiasis is often mild or asymptomatic in over 50%-60% of cases, but may present with cutaneous and gastrointestinal symptoms like abdominal pain, bloating and diarrhea. The rise in blood eosinophils count could be the only finding. Strongyloides is able to re-infect the host through the wall of gastrointestinal tract, a process described as autoinfection. This is why it may be detected decades after original exposure.

CASE DESCRIPTION/METHODS:

We encounter a 64-year old Hispanic male with PMH of Multiple Myeloma, who was admitted to our hospital due to fatigue and spiking fever. Patient was recently diagnosed with Multiple Myeloma and was on Bortezomib, Cyclophosphamide and Dexamethasone for the last 22 days. During the presentation, maculopapular rash was noted on his right inner thigh that later on got more diffused and affected the bilateral thigh and right forearm. Laboratory results shows Leukocyte 6.8 thousand/uL, hemoglobin 7.3 g/dL, platelet 35 thousand/uL, eosinophil 34 cells/uL, and plasma cell 2 cells. Patient had Tmax of 103 and empiric antibiotic was started. All blood cultures, urine cultures and chest X-ray was negative for any source. His liver enzymes and direct bilirubin trended up without any sign of cholecystitis on ultrasound and Cholescintigraphy scan. During the hospital course, the rash got more characteristic of reticulated purpuric patches. EBV, HSV, Varicella, Spotted fever, Typhus fever, ANA, IGG and hepatitis panel back negative. Due to reticular rash development, suspicion of Strongyloidiasis increased and IGG antibody came back positive. Patient started on Stromectol 15 mg for 2 doses and the rash resolved following the second dose of the medication.

DISCUSSION:

Strongyloides stercoralis is a challenging diagnosis in immunocompromised patients. It is important to screen for helminth diseases in patients with high blood eosinophils count, especially before starting chemotherapy.
1576 Use of Intravenous Immunoglobulin as a Treatment Adjunct for Refractory Clostridioides difficile Infection
Authors: Quinn Michael , Ghanekar Dilip , Venu Lakshminarasimhan , Kang Gurjeet , Orpiano Christopher L. , Staffetti Joseph
Published: October 2019

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.
1578 A Rare Follicular Lymphoma of the Colon
Authors: Truscello David , Shah Maulik , Kolnik John
Published: October 2019

INTRODUCTION:

Here we present a case of intestinal follicular lymphoma (IFL) originating in the colon. Pathology was confirmed from multiple institutions and the authors of this report could only find a few such instances in literature. We will go through the case, the diagnosis, endoscopic pictures, as well as patient outcome.

CASE DESCRIPTION/METHODS:

A 60 year old male presented for a routine screening colonoscopy. A single polyp, measuring between 10 and 20 mm, was found in the colon, 30 cm from entry site and removed with snare cautery polypectomy. Initial pathology was consistent with low grade B-Cell Lymphoma of possible marginal zone origin that was positive for BCL2, CD20, CD43, and Ki-67. A year later patient presented for follow up colonoscopy in which two additional polyps were found, one at the splenic flexure, one at 50 cm. Both of their pathology was CD10, CD20 positive and consistent with follicular lymphoma, grade 2. This finding was also confirmed by a reputable pathologist in a different health system. The recent polyps do bring into question as to whether the initial polyp was also follicular lymphoma. Patient underwent a subsequent bone marrow biopsy at the time that showed small atypical lymphoid aggregates.

DISCUSSION:

Intestinal follicular lymphomas (IFL) are a subtype of Non-Hodgkin's lymphoma that account from anywhere to 1-3.6% of all cases. Although there are not many cases present in literature, the authors did find a study indicating older caucasians were more prone to this diagnosis. While some patients present for evaluation of gastrointestinal complaints, our patient was asymptomatic when he presented for a routine colonoscopy. Multiple polyps were found that were consistent with lymphoma pathology. Most of these cases present on endoscopic evaluation as elevated lesions with no erosions or ulcerations. Consistent with primary follicular lymphomas, our patient's pathology also exhibited positive CD10 and CD20 immunohistochemical markers. Takata et al. reviewed prior cases of IFL and determined the small intestine is the most common site. However, multiple reports site that primary colon IFL only accounts for about 1-2% of IFL. Despite its rarity, the prognosis is fairly well with Chouhan et al. indicating a 5 year OS rate of 71.5%. The traditional FLIPI and FLIPI2 prognostic scales could not be used in this case as there have not been enough IFL cases to prove the effectiveness of this method. Our patient has since been stable in the 4 years following his latest polyp removal.
1579 Rare Finding of Incidental Ascending Colon Ganglioneuroma in the Setting of Hematochezia
Authors: Nehme Christian , Ghazaleh Sami , Ghanim Marcel , Khader Yasmin , Hasan Syed , Nawras Ali
Published: October 2019

INTRODUCTION:

Ganglioneuromas are slowing growing tumors that are rarely found in the colon. Patients with colonic ganglioneuromas may present with nonspecific symptoms such as abdominal pain, bleeding, or change in bowel habits, but these patients are usually asymptomatic. We present a case of hematochezia where an ascending colon ganglioneuroma was incidentally found on diagnostic colonoscopy.

CASE DESCRIPTION/METHODS:

84 year old male with a past medical history of hypertension, chronic atrial fibrillation on rivaroxaban, COPD, and prostate cancer S/P radiation presented with hematochezia of two days duration. He had three loose bowel movements on the day of presentation with bright red blood and clots. This was associated with nausea and diarrhea, but patient denied abdominal pain, vomiting, hematemesis, melena, and weight loss. Last colonoscopy, around 7 years ago, was normal. On presentation, patient's vital signs were within normal limits. Physical exam revealed an irregularly irregular rhythm. Abdominal exam was within normal range. Rectal exam revealed dark red stools. No external hemorrhoids were seen. Laboratory findings revealed hemoglobin of 12.5 g/dl and an INR of 1.4 Rivaroxaban was stopped on presentation. Hemoglobin dropped to 11 g/dl then became stable. Colonoscopy was performed five days later. It showed a 3 mm polyp in the ascending colon, a 4 mm polyp in the descending colon, and diverticulosis in the descending colon. The 3 mm polyp in the ascending colon was removed with a cold biopsy forceps. Histological examination of the specimen showed ganglioneuroma.

DISCUSSION:

Ganglioneuromas are hamartomatous tumors that are rarely seen in the gastrointestinal tract, and are usually found incidentally. There are three different subtypes of ganglioneuromas: polypoid ganglioneuroma, ganglioneuromatous polyposis, and diffuse ganglioneuromatosis. The most common type is polypoid ganglioneuroma which is usually a small single polyp arising from the mucosa and submucosa. Definitive diagnosis of ganglioneuroma can only be done through pathological and histological examination. Treatment depends on their size, location, and subtype in addition to the patient's clinical history. Polypoid ganglioneuroma, which is present in this patient, is a benign lesion, so endoscopic resection using a biopsy forceps or a snare is usually curative. It may also be useful to perform a follow up colonoscopy to ensure complete excision of the lesion.
1584 A Rare Case of Follicular Lymphoma of Sigmoid Colon
Authors: Mohy-ud-din Nabeeha , Umar Shifa , Kulkarni Abhijit , Morrissey Suzanne
Published: October 2019

INTRODUCTION:

Follicular lymphoma is defined as a neoplasm of follicle B cells and is characterized immunohistochemically by a positive reaction to B-cell markers and Bcl-2. Follicular lymphomas of the colon are very rare. Within GI Lymphomas, colorectal lymphomas are very uncommon and account for only 3% of GI lymphomas and 0.3% of large intestinal malignancies. We describe an unusual presentation of extra-nodal follicular lymphoma within the sigmoid colon.

CASE DESCRIPTION/METHODS:

A 59-year-old Caucasian female with history of hypertension was referred by her primary care physician for an average risk screening colonoscopy. Prior to referral for screening colonoscopy, the patient was being screened for colon cancer with annual occult stool testing which had been negative. She underwent a colonoscopy which showed a sessile polyp in the hepatic flexure and two polypoid lesions in the sigmoid colon (Figure 1). The patient was referred for endoscopic mucosal resection of the polyps. A snare mucosal resection was performed for the hepatic flexure polyp (12 mm in size). The 2 sessile polyps in the sigmoid colon (8-12 mm in size) were also resected with a hot snare. Pathology from the sigmoid colon polyp was consistent with Grade IIIA Follicular Lymphoma and immunohistochemistry was positive for CD20, CD10, BCL6 and BCL2 (Figure 2). The polyp in the hepatic flexure was noted to be a benign sessile serrated polyp. Patient was referred to Oncology for further management. A bone marrow biopsy and PET/CT did not show any evidence of disease involvement elsewhere.

DISCUSSION:

Primary NHLs of the GI tract are rare, accounting for only 1 to 4 percent of malignancies arising in the stomach, small intestine, or colon. Colonoscopy with biopsy is the principal diagnostic modality. Colonoscopic findings of follicular lymphomas include mucosal ulcerations, diffuse mucosal nodularity or polypoid mass like lesions. However, due to its rarity, an optimal diagnostic work up and treatment plan has not been well established. Making a correct diagnosis of the disease based on findings of biopsied samples can be challenging and multiple biopsies or endoscopic mucosal resection may be required in addition to appropriate consultation with pathologists.
1587 Ogilvie Syndrome Associated With Chronic Baclofen Use
Authors: Akhtar Nabeel , Kim Alex , Bhaskar Benny , Coates Matthew
Published: October 2019

INTRODUCTION:

Ogilvie syndrome is common in hospitalized patients and can be contributed by medications such as opioids and anti-cholinergics. We present a case of a 70 year-old male with Ogilvie syndrome associated with chronic baclofen use.

CASE DESCRIPTION/METHODS:

A 70 year-old male with chronic obstructive pulmonary disease (COPD), peripheral neuropathy and spastic hemiplegia treated with baclofen for four years presented to the emergency room with a four-day history of progressively worsening abdominal distension, constipation, poor oral intake, and reduced urine output. He was hospitalized for a COPD exacerbation managed with steroids and breathing treatments. Physical examination demonstrated a significantly distended abdomen without bowel sounds and mild tenderness to palpation without peritoneal signs. Blood tests did not note any electrolyte disturbances. CT imaging without contrast showed gaseous distension of the colon with scattered stool and compression deformities of the T8, T9, T11, L1 and L5 vertebrae. Concerning for an ileus or colonic obstruction, patient was made nil per os (NPO) and had nasogastric and rectal tubes inserted. Despite an aggressive bowel regimen including polyethylene glycol, senna, and rectal enemas, patient's gastrointestinal symptoms did not resolve. Repeat exams demonstrated progressive distension and tenderness to palpation. Abdominal x-ray (AXR) showed persistently dilated large bowel loops and a possible transition point in the distal sigmoid colon. He then underwent a flexible sigmoidoscopy for further evaluation and stool disimpaction; no physical obstruction was encountered, but the colonoscope did not pass beyond the sigmoid colon due to a considerable solid stool burden. He was continued on a bowel regimen with trials of lubiprostone and neostigmine; however, these interventions only led to modest liquid stool output. Finally, baclofen was discontinued, and in the next day, the patient passed solid bowel movements with progressive improvement in his exams. Post-discharge, repeat AXR showed decreased gaseous distension of the transverse and descending colon. Patient was advised to discontinue baclofen.

DISCUSSION:

Medications can lead to colonic pseudo-obstruction - Ogilvie syndrome - particularly in people with severe comorbidities or acute illnesses. Baclofen has previously been associated with Ogilvie syndrome. When prescribing baclofen, providers must warn patients to monitor stool output and strongly consider administering a bowel regimen.
1589 Unusual Presentation of Adenocarcinoma Ex Goblet Cell Carcinoid
Authors: Rojas Patricia Guzman , Gonzaga Ernesto Robalino , Henriquez Richard , Parikh Jignesh
Published: October 2019

INTRODUCTION:

Ex Goblet cell carcinoid (eGCC) is a type of goblet cell carcinoid tumor, characterized by both endocrine and exocrine features, that has carcinomatous growth patterns. The classical presentation is compatible with symptoms of acute appendicitis. However, other signs and symptoms such as bowel obstruction, GI bleed and less commonly mesenteric adenitis or iron deficiency have been reported.

CASE DESCRIPTION/METHODS:

A 72 year old man with a recent hospitalization due to symptomatic anemia, presented to the ED complaining of diffuse abdominal pain for the past 3 weeks. He also reported nausea and emesis for 12 hours. At the previous admission, a CTE (Figure 1) showed thickening of the TI and an EGD was unremarkable. A colonoscopy was recommended, but it was scheduled for completion as an outpatient. At this admission, his hemoglobin was within normal limits, however his abdominal pain and nausea were persistent despite medical treatment. A repeated CT abdomen showed the same TI thickening with an associated new SBO (Figure 2). General surgery was then consulted and the patient underwent an exploratory laparotomy. Intraoperative findings showed possible carcinomatosis, and thence an ileocolectomy and ileocolostomy were performed. Pathology findings were compatible with adenocarcinoma ex goblet cell carcinoid of the appendix (Figure 3), and for this reason, he was referred to oncology for further management.

DISCUSSION:

GCC can be classified into 3 groups according to the presence of adenocarcinoma component and its degree of differentiation which directly correlates with its prognosis. Group A exhibits only pure goblet cell carcinoid cells; group B shows goblet cells with signet ring cells, and group C presents with goblet cell cells with a component of adenocarcinoma. eGCC corresponds with group C, which is the type presented in our case. Most patients have metastatic disease at the time of diagnosis, estimated in 60% to 91% of the cases. Due to the rarity of this type of tumor, currently there are no guidelines for treatment. However, the main approach is based on surgical resection of the appendix versus right hemicolectomy if the tumor is not confined to the submucosa. In terms of adjuvant treatment, FOLFOX/FOLFIRI are currently being used in most institutions. We present this patient due to its rarity and unusual presentation. Furthermore, we would like to incentivize future researches that can focus on implementing treatment guidelines for this tumor, due to its associated poor prognosis.
1591 Melanosis Coli Aids Endoscopic Differentiation of Polyp Histology in Cowden Syndrome
Authors: Farah Filsan , Pearlman Rachel , Arnold Christina , Stanich Peter P.
Published: October 2019

INTRODUCTION:

Cowden syndrome is a rare disorder related to germline mutations in the PTEN gene. Although considered a hamartomatous polyposis syndrome, emerging evidence has shown colorectal polyposis with mixed histologic types (including adenomas) to be most common. This can make endoscopic surveillance difficult. Melanosis coli is characterized by dark pigmentation of the colon. Adenomatous and hyperplastic polyps remain pale in this setting and are easily visualized, but there are no published reports on the appearance of hamartomatous polyps.

CASE DESCRIPTION/METHODS:

A 55-year-old man with intellectual disability was referred to our institution for consideration of colectomy due to colorectal polyposis. He was then referred to GI Genetics clinic for further evaluation prior to surgery. His history included innumerable colon polyps on previous colonoscopies. Available pathology included multiple colon polyp types including tubulovillous and tubular adenoma, serrated adenoma, hyperplastic and inflammatory polyps. His family history included twin brother with brain tumor, mother with breast cancer and stomach cancer and father with brain cancer. Examination showed macrocephaly with head circumference of 62 cm. Cowden syndrome was suspected and genetic testing was performed. This showed a pathogenic mutation in the PTEN gene and confirmed the diagnosis. Surveillance colonoscopy was performed. This showed diffuse melanosis and polyposis of the colon. There were 4 colon polyps that were pale and visually consistent with adenomas. These were resected and returned as 3 tubular adenomas and a serrated adenoma with minimally apparent melanosis on histologic assessment. There were multiple diminutive polyps throughout the colon that were dark and appeared visually consistent with hamartomas. Many of these were sampled and were consistent with hamartomatous polyps with prominent melanosis histologically. Given the ability to endoscopically differentiate between neoplastic and benign polyp histologies, ongoing surveillance colonoscopy was recommended and colectomy was avoided.

DISCUSSION:

Polyposis with mixed polyp histology is common in Cowden syndrome and complicates endoscopic surveillance. In our patient with melanosis coli, hamartomatous polyps remained dark and matched the surrounding mucosa while adenomas and serrated adenomas were pale and easily distinguishable. This is the first report of the appearance of hamartomas in the setting of melanosis to our knowledge.