bluuebunny/crossref_metadata_2025_split huggingface dataset:
2079 Coexistence of Lymphocytic Colitis in a Patient With Ulcerative Colitis
Authors: Sadiq Omar , Alimirah Maryam , Kanduru Chakravarthy 
Published: October 2019

INTRODUCTION:
Microscopic colitis (MC) is an inflammatory condition of the colon that is histologically divided into two different conditions, lymphocytic colitis (LC) and collagenous colitis. Initially suspected to be unrelated to inflammatory bowel disease, a growing body of evidence now suggests a common pathophysiology between MC and IBD. We describe a case report of a patient presenting with both LC and UC.

CASE DESCRIPTION/METHODS:
A 59-year-old Caucasian, nonsmoking female with a history of diabetes underwent a colonoscopy for evaluation of constipation which demonstrated significant colitis, consistent with UC. Her disease was managed with mesalamine however due to social restrictions, clinical follow up and management of her disease was limited. As part of age appropriate management, patient underwent routine screening colonoscopy 15 years after her initial diagnosis as an open access procedure. During the procedure patient was noted to have terminal ileum apthae with Mayo score 2 pancolitis. Random biopsies taken during the procedure demonstrated focal acute inflammation. In follow up clinic visit, patient endorsed having 3-4 non-bloody, loose bowel movements daily but was otherwise asymptomatic. She was started on balsalazide capsules with improvement in stool consistency and reduction in frequency of bowel movements. Shortly after starting balsalazide patient lost insurance access and was unable to follow up as directed. Patient returned to gastroenterology clinic two years later endorsing 4-5 non-bloody, loose bowel movements every day. Fecal calprotectin at this time was noted to be 26.7 mg/kg (normal < 50 mg/kg) however due to ongoing symptoms balsalazide was restarted. Repeat colonoscopy was performed to evaluate for dysplasia and ongoing symptoms which demonstrated Mayo score 1 pancolitis. Random biopsies taken during the procedure demonstrated chronic active colitis with superimposed lymphocytic colitis. Patient was started on budesonide in addition to balsalazide with reduction in stool frequency and improvement in consistency.

DISCUSSION:
In literature, coexistence of UC and LC is described in 12 cases, typically in patients with complete remission of UC. Here we describe a case of active UC further complicated by lymphocytic colitis which was successfully managed with a combination of a 5-aminosalicyclic-acid derivative and glucocorticoids. This case emphasizes the importance of looking for alternative causes of symptoms in patients with mild colonoscopic findings.
2090 EBV Colitis With Fulminate Ulcerative Colitis: A Clinical Dilemma
Authors: Lindsey Adrian , Ahmad Dina , Kurin Michael , Sinh Preetika , Lisgaris Michelle , Rodriguez Benigno , Nguyen David , Charles Ronald , Farag Rosemary 
Published: October 2019

INTRODUCTION:
Epstein-Barr virus (EBV) is a virus of the herpes family. EBV can be detected in the gastrointestinal tissue of patients with inflammatory bowel disease(IBD). However, the clinical significance of EBV colitis in ulcerative colitis (UC) is unclear. We present an interesting and rare case of EBV colitis in a patient with fulminant UC.

CASE DESCRIPTION/METHODS:
A 73-year-old male with history of hypertension and recent diagnosis of UC who was doing well on mesalamine developed a flare with acute onset diarrhea, abdominal pain, and rectal bleeding. Stool tests were negative for C difficile and common bacterial and viral pathogens. Fecal calprotectin was >2000 μg/mg, and CT abdomen/pelvis was notable for thickened colon walls. Colonoscopy showed moderate inflammation with aphthous ulcerations throughout the colon with sparing of the cecum. Patient was started on oral steroids and transitioned to adalimumab. He continued to have weight loss and diarrhea and was switched to vedolizumab after two months. Due to continued symptoms, repeat colonoscopy 6 months later showed severe inflammation with confluent ulcerations in continuous and circumferential pattern from rectum to transverse colon (Figure 1). Laboratory workup was notable for anemia (hgb 9.0 g/dL), hypoalbuminemia (2.9 g/dL) and high C-reactive protein (3.22 mg/dL). Patient was admitted for IV steroids. Infliximab was started on day 5 due to no improvement in symptoms. At this time biopsies obtained during colonoscopy were reported to be positive for EBV-encoded small RNA by in-situ hybridization (Figure 2). EBV was also detected in whole blood by PCR. IV gancyclovir was started. After 7 days of treatment with gancyclovir, repeat flexible sigmoidoscopy showed no significant improvement. Immunostains for EBV, CMV, and HSV were negative. EBV PCR declined (60,000 to 30,000 IU/ml). A subtotal abdominal colectomy with end ileostomy and rectal stump was eventually performed without any complications. Patient gained weight and did well post operatively.

DISCUSSION:
EBV colitis with fulminant UC is rare. The clinical implication of EBV colitis and treatment benefits are unclear. In addition, there is lack of a standard therapy for EBV infection with case reports showing improvement with gancyclovir. Our case of true EBV colitis with fulminant UC illustrates the importance of considering a superimposed infection in patients with IBD refractory to steroids and immunosuppressive therapy early in the course of the disease to prevent progression.
2091 Orofacial Granulomatosis: The Proof Is in the (Cinnamon) Pudding
Authors: Crooks Benjamin J. , Limdi Jimmy K. 
Published: October 2019

INTRODUCTION:
Orofacial granulomatosis (OFG) can present in isolation or in conjunction with other systemic disease including Crohn’s disease (CD). Data suggests that CD presenting with OFG may represent a distinct sub-phenotype of CD with more extensive inflammation and perianal disease [1]. Treatment of the oral manifestations of CD is typically challenging with numerous strategies proposed including topical and intralesional agents, immunomodulators, biological agents and dietary interventions.

CASE DESCRIPTION/METHODS:
A 24-year-old female with CD affecting the upper gastrointestinal tract, small and large bowel and perianal disease was referred to our unit for further management. She was diagnosed at the age of 19 when she had an emergency admission with jejunal obstruction. A jejunal resection with primary anastomosis was performed. She was managed with Infliximab and Azathioprine. She developed thickening of her buccal mucosa (Figure 1). A biopsy confirmed chronic inflammation with several non-necrotic granulomas in keeping with OFG. The patient was commenced on prednisolone with some improvement of the oral swelling however it later recurred requiring further oral steroids. Despite pro-active optimisation of Infliximab and Azathioprine levels, her oral manifestations of Crohn’s disease worsen (Figure 2). A cinnamon- and benzoate-free diet was recommended in liaison with specialist IBD dietitians with a dramatic improvement of her oral swelling within 4 weeks and near resolution in 8 weeks (Figure 3). Following 12 months of the diet the patient was advised to start re-introducing cinnamon and benzoates gradually into her diet and since this there has been no recurrence of oral symptoms. She has been maintained on an anti-TNF and Azathioprine for treatment of her ileo-colonic and perianal disease.

DISCUSSION:
There is good evidence for the efficacy of a cinnamon- and benzoate-free diet in patients with OFG raising the possibility of a dietary antigen and subsequent hypersensitivity in its aetiology. In our case the excellent response of the OFG to this diet, following failure to respond to conventional treatment for CD, is of interest. The debate regarding whether OFG is a distinct disease entity from oral CD continues. More studies are required to guide treatment options in this group of patients.
2093 Uncharted Territory: Biologic Therapies for Elderly Patients With Refractory Ulcerative Colitis
Authors: Figueredo Carlos , Boroda Konstantin , Hertan Hilary 
Published: October 2019

INTRODUCTION:
Ulcerative colitis (UC) is becoming more common among people older than 65. However, diagnosis in these patients is challenging due to the presence of comorbidities that can resemble UC and symptoms being more subtle. UC treatment guidelines are based on trials of short duration that often exclude elderly patients. Therefore, when treating this population, choice of therapy should be tailored for each patient individually. The use of biologic agents in this population is controversial given the lack of strong evidence-based trials; with most data coming from the rheumatology literature. It can also be difficult as benefits are masked by multiple comorbidities and long term progression of the disease. We present a case series of two patients with refractory UC who had good outcomes with biologic therapy.

CASE DESCRIPTION/METHODS:
Case 1: 87-year-old male with left sided UC and history of prostate cancer treated with brachytherapy in 2013, complicated by radiation proctitis. He was initially maintained on 5-ASA, but had numerous hospitalizations with persistent diarrhea, rectal bleeding, dehydration, and C. difficile colitis over the course of 1 year. Sigmoidoscopy revealed severe “Mayo 3” colitis (Figures 1 and 2). He became steroid dependent, so was then started on adalimumab with improvement of his Disease Activity Index and no further UC related hospitalizations. Case 2: 80-year-old female with severe UC pancolitis diagnosed in 2017 and comorbidities of HTN, NIDMM, HLD, asthma, GERD, and stroke. She was initially on mesalamine enemas, which she did not tolerate due to a salicylate allergy. She was then switched to hydrocortisone enemas, then switched to adalimumab, with resultant persistent recurrence of flares. She is now on infliximab and in remission since 2018.

DISCUSSION:
The efficacy of biologic agents in the elderly UC patients, as compared to younger patients, has not been studied extensively. However, our experience has shown good outcomes in this population. Possible adverse effects of anti-TNF therapy include higher rates of cardiovascular diseases (e.g, heart failure), malignancy, psoriasis, and opportunistic infections. Advantages of this therapy are low rates of drug interactions and lesser impact on comorbidities when compared with usual treatments like steroids or 6-MP. Our experience supports the use of biologics in elderly patients with refractory UC.
2094 Segmental Colitis Associated With Diverticulosis Progressing to Ulcerative Colitis: An Under-Reported Occurrence
Authors: Omer Anam , Pinillios Hugo L. 
Published: October 2019

INTRODUCTION:
Segmental colitis associated with diverticulosis (SCAD) is chronic inflammation of the interdiverticular mucosa, usually involving the sigmoid colon. This entity may mimic ulcerative colitis (UC) in its clinical manifestations and endoscopic appearance, however unlike UC, the rectum is usually spared. We report a rare case of SCAD progressing UC.

CASE DESCRIPTION/METHODS:
A 59-year-old female was referred for an outpatient colonoscopy for evaluation of a two-month history of hematochezia and diarrhea. Past medical history was significant for gastroesophageal reflux disease with esophagitis. Physical examination revealed no tenderness in the abdomen and normal bowel sounds. Rectal exam revealed small non-bleeding external hemorrhoids. Laboratory examination was significant for a low hemoglobin of 11.4 g/dL. Colonoscopy revealed patchy loss of vascular pattern, edema and hyperemia in the sigmoid colon associated with several large diverticula. Rest of the colon including the rectum and terminal ileum was unremarkable. Histologic evaluation of the specimens taken from the inflamed sigmoid colon showed expansion of the lamina propria with moderate chronic inflammation. No acute inflammation including acute cystitis or crypt abscess was present. The patient was diagnosed with SCAD and prescribed a two-week course of antibiotics with partial improvement in her symptoms. The patient was lost to follow-up for two years and presented again with hematochezia and iron deficiency anemia. A repeat colonoscopy revealed mild rectal erythema and an interval increase in inflammation of the sigmoid colon typical for UC. Several pseudopolyps were also seen. Histologic examination of the specimens taken from the sigmoid colon and rectum showed severe chronic active colitis with crypt architectural distortion compatible with UC. Crypt architectural distortion was also noted in the remaining endoscopically normal colon.

DISCUSSION:
The pathogenesis of SCAD remains unclear, however, mucosa prolapse, fecal stasis and localized ischemia is frequently implicated. Even though SCAD is recognized an independent disease progress, there have been reports of cases of SCAD progressing to inflammatory bowel disease (IBD). A high index of suspicion should be kept for patients with SCAD who do not respond to the main stray of treatment with antibiotics, anti-inflammatory agents and steroids. Also, patients with SCAD should be considered for close follow-up and surveillance endoscopy as this disease may co-exist or progress to IBD.
2095 Hemolytic Uremic Syndrome in a Young Female, Later Diagnosed With Crohn's Disease
Authors: Neupane Rabin , Kohli Akshay 
Published: October 2019

INTRODUCTION:
Hemolytic uremic syndrome (HUS) is defined by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. HUS has mostly been associated with Escherichia Coli infection but also seen with systemic infections, pregnancy, rheumatic disease and malignancies. Although, HUS has been described in previously diagnosed case of crohn’s, concomitant occurrence of both is a rarity. We describe a case of 37-year-old female, with acute onset of HUS, who was subsequently diagnosed with crohn's.

CASE DESCRIPTION/METHODS:
32-year-old female presented with complaints of abdominal pain, and bloody diarrhea for 5 days, which persisted despite antibiotic therapy. In ED, laboratory tests showed anemia, thrombocytopenia, AKI and Lactic acidosis. Her hemoglobin dropped to 6.7 g/dl and platelets went down to 48k. LDH was elevated and haptoglobin was low. Peripheral smear showed moderate schistocytes. However, shiga toxin was negative. Patient was managed symptomatically for HUS but her symptoms persisted. Imaging revealed thick-walled transverse and left colon. Colonoscopy showed mucosal ulceration and severe colitis with shallow and deep ulcers in ascending, transverse, and descending colon but rectum was normal. Push enteroscopy revealed a small esophageal ulcer. Biopsy showed granulomatous inflammation suggestive of Crohn's. Hence the patient was started on sulfasalazine. Patient had significant clinical recovery within a month and repeat colonoscopy showed healing congested mucosa.

DISCUSSION:
Although HUS is predominantly described in the pediatric population, its incidence is rising in adult population. It has been found to involve the transverse and ascending colon, much like Crohn's disease. A few reported cases has showed interchanging clinical features between HUS and IBD. Cumulative occurrence of the both was considered rare, however, cases of HUS in patient who were already diagnosed with Crohn's has been seen. In this case, the patient presented with the clinical features of HUS as her first and only manifestation of her Crohn's. Rapid recovery and resolution of symptoms within four weeks of starting the appropriate treatment presents the importance of the appropriate management on the clinical recovery. Hence, with the growing incidence of concurrent occurrence of both entities, early colonoscopy with biopsy can be beneficial in cases of HUS not responding to treatment, even if the patient has no history of IBD, as this could be their first presentation.
2097 A Double Whammy: A Case of Anterior Uveitis and Optic Neuritis in Patient With Crohn’s Disease on TNF Inhibitor Therapy
Authors: Kang William D. , Dominguez Cristian , Sayana Hari 
Published: October 2019

INTRODUCTION:
Crohn’s disease (CD) is characterized by chronic transmural inflammation which can be managed with TNF inhibitor therapy. These medications are overall safe but can have uncommon yet significant side effects. This is a case of anterior uveitis with underlying optic neuritis secondary to chronic anti-TNF therapy.

CASE DESCRIPTION/METHODS:
A 53-year-old male with a history of Crohn’s colitis diagnosed in 1997, presented to ophthalmology with bilateral decreased visual acuity. He had failed multiple therapies for CD in the past, including Infliximab, Certoluzimab, azathioprine, and Methotrexate. He was on clinical remission on Adalimumab and oral mesalamine. Prior to therapy 18 months ago, his most recent colonoscopy showed mild to moderate pancolitis with a normal terminal ileum. He then presented to Ophthalmology with a 10-month history of bilateral blurry vision, erythema, irritation, photophobia, and diplopia. On exam, he was noted to have decreased visual acuity 20/80 bilaterally, left superior temporal and nasal field deficiencies, right optic disc pallor and left optic nerve swelling. A diagnosis of anterior uveitis was made and patient referred for evaluation by neuro-ophthalmology, who confirmed a diagnosis of optic disc neuritis, which was attributed to chronic TNF inhibitor therapy. A previous work up with a MRI of the brain and temporal artery biopsies had been non-diagnostic. He was diagnosed with anterior uveitis and was started on Prednisolone eye drops. The Adalimumab was discontinued, and the patient declined Vedolizumab as an alternative therapy. Most recently, he had one acute episode of vision loss in February of 2019 that was treated with IVIG but reports stabilized visual acuity and eye pain since then.

DISCUSSION:
There have been rare reports of approximately 1 in 1000 patients using TNF inhibitor drugs who experience de-novo or unmasking of latent demyelinating disease including optic neuritis. Both partial improvement and complete resolution of symptoms from optic neuritis has been reported upon discontinuation of TNF inhibitor therapy. Our patient continues to be off all biologics and his vision continues to improve.
2100 Linear IgA Bullous Dermatosis, Ulcerative Colitis, and Autoimmune Hepatitis: A Unique Triad
Authors: Kothari Shana , Berkelhammer Charles 
Published: October 2019

INTRODUCTION:
Linear immunoglobulin IgA bullous dermatosis (LABD) is an autoimmune bullous disease characterized by formation of subepidermal blisters and linear deposition of IgA antibodies along the basement membrane zone. The link between LABD and ulcerative colitis (UC) has been previously documented and hypothesized to be due to immune exposure to autoantigens present in the colon, and subsequent targeting of these autoantigens in the skin. However, there have been no associated cases with autoimmune hepatitis. We report a unique triad of all three autoimmune conditions that presented concomitantly.

CASE DESCRIPTION/METHODS:
A 21-year-old male presented with vesicular and pustular rash on the skin of the hands, arms, abdomen, and legs (Figure 1). Histopathology revealed subepidermal blister with perivascular inflammation and linear C3 and IgA deposition along dermoepidermal junction consistent with LABD. The rash did not respond to topical corticosteroids. Liver enzymes were markedly elevated (AST 535 unit/L, ALT 436 unit/L, ALP 292 unit/L, bilirubin 0.3 mg/dL). He had iron deficiency anemia (Hgb 10.9 gm/dL, MCV 72.3 FL) with low ferritin. Autoimmune markers including antinuclear antibody, anti-smooth muscle, F-actin, anti-mitochondrial antibody, anti-liver kidney microsomal antibody, and anti-neutrophil cytoplasmic antibody were negative. Viral markers including Epstein Barr virus, cytomegalovirus, hepatitis A, B, C, E were negative, as were markers of metabolic liver disease. Celiac serologies were negative. Liver ultrasound was significant for hepatomegaly. Upper endoscopy with small bowel biopsies were normal. Colonoscopy revealed a patchy pancolitis consistent with ulcerative colitis, confirmed on biopsies. Prednisone 40 mg daily was administered, resulting in rapid resolution of the rash and elevated liver enzymes. Rapid improvement of transaminases with corticosteroids favors seronegative autoimmune hepatitis. He remains in clinical remission of his LABD, ulcerative colitis, and seronegative autoimmune hepatitis after gradual tapering off corticosteroids and on mesalamine alone.

DISCUSSION:
This is the first case, to our knowledge, where LABD, UC, and autoimmune hepatitis coexisted and had a successful therapeutic response to systemic corticosteroids. It is imperative to consider concomitant autoimmune diseases when a patient presents with such skin manifestations in order to guide early treatment.
2101 Non-Necrotizing Granulomas of the GI Tract and Abdominal Lymph Nodes. Crohn’s Disease, Sarcoidosis or Both?
Authors: Douglas Scott R. , Lotun Nitisha , Moore Danielle , Doran Amy , Hays R. Ann 
Published: October 2019

INTRODUCTION:
Digestive tract involvement of sarcoidosis is rare (<2%) with few case reports of gastric and colon involvement and requires the presence of non-necrotizing granulomas. Non-necrotizing granulomas of the GI tract are typically associated with either Crohn’s disease or sarcoidosis. Distinguishing between the two can be a diagnostic dilemma.

CASE DESCRIPTION/METHODS:
A 25 y.o African American male presented with nausea, vomiting and weight loss. CT showed diffuse nodular airspace disease, lymphadenopathy, and thickening of the antrum and proximal duodenum. Lymphadenopathy involved the porta hepatis, stomach, head of the pancreas, abdominal mesentery, retroperitoneum and groin. EGD/EUS revealed mild erosive gastritis and duodenitis. Gastric and duodenal biopsies revealed non-necrotizing granulomas. Lymph node FNA showed reactive lymphocytes and non-necrotizing granulomas. Flow cytometry was normal. Colonoscopy with biopsy found nodular lymphoid hyperplasia in the terminal ileum (TI). Serum ACE level, lysozyme, and IgG4 were normal. IgG 3 was elevated. PFTs showed mildly reduced DLCO. Infectious work up was negative. He was treated with steroids and improved clinically. Three years later he presented with recurrent epigastric pain, anorexia, early satiety and profound weight loss. CT revealed increased abdominal lymphadenopathy. EGD showed inflammation and thickening of the stomach and duodenum. CSY revealed TI lymphoid hyperplasia, erosions over the IC valve and mild right sided colitis (Figure 1). Histology showed non-necrotizing granulomas with acute/chronic inflammation in the right colon, duodenum and stomach. CT chest showed regression of findings compared to 2016. Work-up revealed normal amyloid, ACE and soluble IL2 Ab receptor. Hypergammaglobulemia and hypoalbuminemia were present. He was treated with prednisone with rapid improvement.

DISCUSSION:
Our case demonstrates difficulty clarifying the diagnosis of non-necrotizing granulomas and distinguishing between atypical Crohn’s and sarcoidosis. Evidence of pulmonary involvement, low DLCO, lymphadenopathy and hypergammaglobulinemia argue in favor of sarcoidosis. Progression of inflammation to the TI and colon suggest Crohn’s. Pathology noted that granulomas were more abundant than commonly seen with Crohn’s disease alone. Additionally, there was more background inflammation than typically seen in GI sarcoid alone. A multidisciplinary team determined that this was consistent with Crohn’s and sarcoidosis occurring concomitantly.