bluuebunny/crossref_metadata_2025_split huggingface dataset:
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.