bluuebunny/crossref_metadata_2025_split huggingface dataset:
2492 Everolimus-Induced Transaminitis in the Setting of Stage IV Carcinoid Tumor With Liver Metastasis
Authors: Nehme Christian , Ghazaleh Sami , Ghanim Marcel , Nesheiwat Zeid , Awad Mohammed , Khader Yasmin , Nawras Ali 
Published: October 2019

INTRODUCTION:
Everolimus may lead to mild and asymptomatic liver enzymes elevation in up to a quarter of the patients taking it, but it rarely leads to symptomatic and significant transaminitis. We describe a case of everolimus induced transaminitis in the setting of stage IV carcinoid tumor with liver metastasis.

CASE DESCRIPTION/METHODS:
A 58-year-old female with a history of stage IV carcinoid tumor with liver metastasis presented with fatigue and worsening epigastric pain. She was first diagnosed with atypical bronchial carcinoids S/P left lower lobe lobectomy and lymph node dissection. Liver metastasis was diagnosed by biopsy two years later. She was started on everolimus one month earlier, and she reports sharp epigastric pain every time she takes the medication. On presentation, patient's vital signs were within normal limits. Physical exam revealed right upper quadrant and epigastric tenderness. Laboratory findings revealed elevated liver enzymes. AST was 723 U/L, ALT was 580 U/L, and alkaline phosphatase was 513 U/L. Total bilirubin was 1.2 mg/dl. To note, liver function tests were normal two weeks earlier. CT scan of the abdomen showed prominent intrahepatic biliary tracts and gallbladder wall thickening. Hepatitis panel and acetaminophen level were negative. Everolimus was discontinued on presentation. On the second day, bilirubin trended up to 1.6 mg/dl. Afterwards, patient's liver enzymes started to trend down and her bilirubin has normalized. Her abdominal pain has resolved. There was no indication at the time for endoscopic intervention.

DISCUSSION:
The trend of the liver enzymes is most consistent with a drug- induced liver injury. Patient was recently started on everolimus which was held on presentation. Liver enzymes started to trend down afterwards. AST and ALT were rapidly improving. Bilirubin became normal. It is important to consider everolimus as a cause of hepatocellular injury when other causes are ruled out.
2500 Pyogenic Liver Abscess Due to Klebsiella ozaenae: An Unlikely Culprit
Authors: Desai Parth M. , Gonzalez Elena , Vohra Ishaan , Mathew Madhu , Lingamaneni Prasanth , Mbachi Chimezie 
Published: October 2019

INTRODUCTION:
Pyogenic liver abscess usually occurs in the setting of peritonitis or cholangitis where seeding may occur through the portal circulation or directly through the biliary tract. Gram negative enteric organisms such as E. coli and K. pneumoniae are most commonly implicated implicated organisms, with gram positives such a Strep species occurring usually in the setting of metastatic infection. Here we describe a case of a pyogenic liver abscess, where Klebsiella ozaenae, a rare pathogen, was isolated from the patient's blood cultures.

CASE DESCRIPTION/METHODS:
A 42 year old gentleman presented to the emergency department with 4 days of severe diffuse abdominal pain and fevers. He was seen 1 day prior in an outside hospital and was discharged from the emergency department. However, he was called the next morning and told that he was growing bacteria in his blood and was told to present to the nearest hospital. On presentation, vital signs revealed a fever of 103 degrees F, heart rate 109, blood pressure 120/70 mmHg. The patient was toxic appearing and had diffuse abdominal tenderness. Laboratory studies were notable for a white cell count of 14.2 k/uL. Serum chemistry and liver function tests were normal. Abdominal CT revealed a mildly lobulated low density lesion in the right hepatic lobe measuring 2.0 by 2.3 cm, with a smaller lesion measuring 0.7 cm and mild surrounding edema. The patient was started on ceftriaxone and metronidazole for coverage of pyogenic liver abscess. The larger lesion was successfully drained by the interventional radiology service, with a favorable clinical response. Two blood culture bottles from the outside hospital grew Klebsiella ozaenae. After initial improvement, patient was discharged home with 4 week course of oral ciprofloxacin and metronidazole and was stable upon follow-up.

DISCUSSION:
Klebsiella ozaenae is a rare cause of infection and bacteremia. It is thought to be a colonizer of the nasopharynx and and is typically associated with chronic atrophic rhinitis. To our knowledge, there has only been one previous case reported of K. ozaenae associated pyogenic liver abscess. Risk factors for bacteremia with K. ozaenae include elderly age, alcohol use, antibiotic exposure, immunosuppression, malignancy and rhinitis. Aminoglycosides, third generation cephalosporins and fluoroquinolones are considered to be drugs of choice for this organism. Clinicians should be aware of K. ozaenae and its potential to cause bacteremia and pyogenic liver abscess.
2506 A Fatal Case of Gemcitabine-Induced Acute Liver Failure
Authors: Hutton Anneka , Takkouche Sahar , Patino Sanja , Cespedes Carlos Miniet 
Published: October 2019

INTRODUCTION:
Gemcitabine is a common chemotherapeutic agent with broad anti-tumor activity. Gemcitabine induced acute liver failure (ALF) is exceedingly rare, resulting in severe steatohepatosis and high mortality. We report the ninth case of Gemcitabine induced ALF.

CASE DESCRIPTION/METHODS:
A 65 year-old female on her second cycle of palliative Gemcitabine for metastatic breast cancer presented with five days of weakness, nausea and vomiting after chemotherapy. She was afebrile but hypotensive. She was not visibly jaundiced, sclerae anicteric, and without palpable hepatomegaly. Her initial labs were significant for elevated direct bilirubin, ALP and transaminitis suggestive of a cholestatic pattern (Figure 1). Notably, she had no hepatic dysfunction one month prior to presentation. Ultrasound revealed fatty infiltration of the liver without evidence of obstruction or acute cholecystitis. She developed worsening steatohepatitis with direct bilirubin predominance (Figure 2). CT abdomen revealed fatty replacement of the liver without obstruction or metastasis. Her course was complicated by severe thrombocytopenia, anemia, and renal failure. She deteriorated despite supportive care, becoming increasingly jaundiced and encephalopathic, expiring on hospital day 5. Table 1.

DISCUSSION:
Chemotherapy agent Gemcitabine is a deoxycitadine analog that incorporates into DNA resulting in apoptosis. Generally well-tolerated, common side effects include myelosuppression and transient elevations in LFTs. However, gemcitabine is implicated as the causative agent of a rare, severe and highly fatal cholestatic ALF. Gemcitabine induced ALF appears idiosyncratic, without clear correlation between dose or duration of treatment. In Gemcitabine induced ALF, imaging shows fatty infiltration of hepatic parenchyma and biopsy reveals hepatocyte ballooning and marked cholestasis. These cases are often rapidly fatal, complicated by thrombocytopenia, coagulopathy and renal failure. Our literature review revealed two cases of patient survival; in one case, Gemcitabine was promptly recognized as the offending agent and high dose steroid therapy was initiated. This may represent a treatment strategy where thus far no others exist. As drug induced hepatotoxicity is the most common cause of ALF in the USA, clinicians should be aware of this hepatotoxic potential, especially given the high mortality rate of Gemcitabine induced ALF.
2515  Rise of the Aminotransferases: A Liver's Call for Help!
Authors: Banerjee Namita , Shrimanker Isha , Singh Pratiksha , Biswal P. , Malini G. 
Published: October 2019

INTRODUCTION:
Acute liver failure is characterized by a biochemical diagnosis of liver damage along with coagulopathy defined by international normalized ratio (INR) >2.0 despite intravenous vitamin K replacement or INR >1.5 with encephalopathy, without any chronic liver disease. It is a rare occurrence in a previously healthy adolescent. We report the case of acute severe hepatitis culminating into acute liver failure with suspected Wilson disease (WD).

CASE DESCRIPTION/METHODS:
A 14-year-old Asian female presented with hematemesis, watery stools and abdominal pain in the right upper quadrant for two days. The patient had 2-3 episodes of vomiting consisting of semi-digested food particles, watery in consistency that gradually progressed to one episode of emesis containing bright-red blood, about 15-20 ml in quantity associated with six episodes of watery stools, without any blood or mucus. She had consumed food cooked outside a few days prior. On admission, she had a pulse of 70 beats/minute, and blood pressure of 98/50 mm Hg. Physical examination revealed icterus, tenderness in the right hypochondriac region and palpable liver, about 3 cm below the costal margin. Laboratory investigations revealed hemoglobin of 10.7 gm/dl, aspartate aminotransferase of 9018 U/L, alanine aminotransferase of 6637 U/L, alkaline phosphatase of 261 U/L, total bilirubin of 2.8 mg/dl with a direct component of 1.6 mg/dl, prothrombin time of 32 seconds, partial thromboplastin time of 39 seconds, international normalized ratio of 2.69. Workup for viral markers was negative. Ultrasound of the abdomen revealed altered echotexture of the liver. The ophthalmologic examination did not reveal any abnormality. The serum ceruloplasmin level was 13 mg/dL. The patient was diagnosed with acute severe hepatitis with acute liver failure with suspected underlying WD. She was treated with intravenous doses of antibiotics including ciprofloxacin and amikacin, vitamin K, and octreotide, oral lactulose and ursodeoxycholic acid and was transfused two units of fresh frozen plasma. A gradual decrease of liver enzymes (Figure 1) and coagulation profile (Figure 2) was seen and she was followed up on an outpatient basis.

DISCUSSION:
The management of acute liver failure can be arduous requiring early diagnosis and aggressive treatment to improve better prognosis. Physicians should maintain a high amount of suspicion of concomitant disease in the setting of a young patient such as ours presenting with fulminant liver disease.
2517 Isn't Herpes Esophagitis Enough?
Authors: Nichols Sarah , Costello Patrick N. , Malkani Anjali 
Published: October 2019

INTRODUCTION:
Herpes simplex (HSV) esophagitis, typically found in immunocompromised hosts, is increasingly being seen in immunocompetent hosts. A PubMed search covering the last 10 years yielded 8 publications of HSV esophagitis in the immunocompetent pediatric population, 3 of which were associated with eosinophilic esophagitis. No literature was found regarding HSV esophagitis associated with H. pylori infection. This is not surprising as the incidence of H. pylori is <10% in developed countries. To our knowledge, this is the first case report of co-infection of HSV esophagitis and H. pylori gastritis.

CASE DESCRIPTION/METHODS:
A healthy 16 year old male presented with 7 days of fever, severe odynophagia, and epigastric pain with no oral ulcers. He had a one year history of heartburn and dysphagia. Family history positive for H. pylori in paternal grandmother. He was seen at multiple facilities prior to transfer with prior diagnosis of costochondritis, pericarditis, pneumonia, and cholecystitis. Work up showed a normal KUB, abdominal ultrasound and upper GI series. WBC was 12.7 × 103/µL with left shift and elevated CRP at 86 mg/L. He was unresponsive to 24 hours of IV acid suppression therapy. Urgent endoscopy revealed extensive shallow ulcerations with exudate of the mid and distal esophagus and mild nodularity of the antrum. Empiric IV acyclovir was started with rapid symptom improvement within 24 hours. Biopsies showed ulcerated squamous esophageal mucosa with acute inflammation and exudate without eosinophilia. Adjacent reactive epithelium included binucleated to multinucleated cells with eosinophil nuclear structures suggestive of Cowdry type A inclusion bodies. A single cell showed a Cowdry type B inclusion but without the presence of classic multinucleated cells with molded nuclei. Immunohistochemistry confirmed the presence of HSV and was negative for CMV. Gastric biopsy showed mild, diffuse chronic gastritis with scant acute inflammation. CLO test was negative, but Diff-Quik and immunohistochemistry stains confirmed H. pylori. Triple therapy for H. pylori and a 10 day acyclovir course were completed. Currently his immune work-up is still pending.

DISCUSSION:
Since herpes esophagitis is a rare diagnosis in pediatrics, it is easy to ignore the possibility of co-infection. The importance of considering a co-infection in acute herpes esophagitis important to consider as the acute symptoms did not explain the patient's chronic peptic symptoms.
2520 Burkitt's Lymphoma of the Duodenum
Authors: Elkhouly Mohamed A. , Attar Bashar M. , Elkafrawy Ahmed A. , Salazar Miguel , Vohra Ishaan , Mutneja Hemant , Chicas Oscar Rivas 
Published: October 2019

INTRODUCTION:
Burkitt's lymphoma is an aggressively growing tumor commonly, involving the jaw and facial bones. A rare variant of this type of lymphoma is found in immunocompromised patients specifically in the gastrointestinal tract, usually affecting the stomach, distal ileum, and cecum and rarely the duodenum. We are reporting a case of primary lymphoma of the duodenum in a patient with newly diagnosed AIDS.

CASE DESCRIPTION/METHODS:
A 50-years-old male with no significant past medical history presented with gradually progressive generalized weakness with easy fatigability of one-month duration. He had no history of shortness of breath, dysphagia, nausea, vomiting, hematemesis, melena, hematochezia or bleeding from any sites. Vitals were normal and examination was negative for abdominal tenderness, organomegaly or lymphadenopathy. Labs showed severe iron deficiency anemia with hemoglobin of 5.9 g/dl with ferritin of 21 ng/ml and Transferrin saturation of 8.8%. Other labs including WBC count, platelets count, creatinine, liver enzymes and LDH were normal. In suspicious of occult gastrointestinal tract bleeding, upper endoscopy was performed revealing a large semi circumferential malignant appearing mass partially obstructing the lumen of the third portion of the duodenum. Multiple biopsied where taken showing small bowel mucosa infiltrated by uniform, intermediate sized cells strongly staining positive for CD10, CD20, Ki-67 (100%) and BCL-6; diagnostic for Burkitt's lymphoma. CT Abdomen/Pelvis/Chest for evaluation of other masses or lymphadenopathy showed a 41 × 40 mm mass arising from the third and fourth portions of the duodenum with short segment wall thickening of the distal small bowel and soft tissue nodule in the right hemipelvis with no significant lymphadenoptahy. His labs reveleaed came positive for HIV-1 with 144,000 and CD4 count of 161. Bone marrow was negative for any involvement He received 2 cycles of alternating chemotherapy with R-CODOX-M and R-IVAC for 4 months duration. PET scan after 2 month of chemotherapy completion was negative for any uptake. Patient is currently doing well, on HAART therapy with no recurrence of his symptoms.

DISCUSSION:
Primary duodenal Burkitt lymphoma is a subtype of non-Hodgkin's lymphoma and represents an aggressive and rare malignancy with only a small number of cases reported worldwide. Clinical and radiological presentation is non-specific and usually mimics other gastric lymphomas, leading usually to late presentation and diagnosis.
2523 A Rare Location for a Rare Gastrointestinal Tumor With a Classical Presentation of Abdominal Pain, and Gastrointestinal Bleeding
Authors: Kesler Alex M. , Tan Winston , Gabriel Emmanuel , Bowman Andrew , Kröner Paul T. 
Published: October 2019

INTRODUCTION:
Yolk sac tumors belong to the class of nonseminomatous germ cell tumor (NSGCT), which rarely present as extragonadal germ cell tumors (GCT) of the retroperitoneum. Patients present with small bowel obstruction or gastrointestinal bleeding. Most commonly, these retroperitoneal tumors affect the ileum or jejunum, but here we present a case of a 31-year-old man who presented with a retroperitoneal yolk sac tumor with associated fistulization to the duodenum, jejunum, and ileum.

CASE DESCRIPTION/METHODS:
A 31 year-old man with no medical or surgical history was admitted with abdominal pain and melena. He underwent contrast-enhanced abdominal computed tomography (CT) showing an enlarging mass with central necrosis, and small bowel fistulization. Gastroenterology was consulted and upper endoscopy was performed, showing evidence of a duodenal mass and fistula, which was biopsied. Initial biopsies were inconclusive. Surgical oncology was consulted, and the patient underwent attempted surgical resection but the majority of the small intestine, colon, and associated mesentery were tethered and resection was not possible. A repeat EGD-guided biopsy was performed and pathology had the histological and immunohistochemical features of a yolk sac tumor. Laboratory studies revealed elevated serum alpha-fetoprotein (AFP) of 992 ng/mL [<6.0 ng/mL], normal serum beta-human chorionic gonadotropin (beta-hCG), and elevated serum lactic acid dehydrogenase (LDH) of 421 U/L [122-222 U/L]. Testicular ultrasound was negative for any abnormalities. Oncology initiated the patient on neoadjuvant cisplatin, etoposide, and bleomycin (BEP) every three weeks for three cycles. Two weeks after starting first cycle, AFP had dropped to 65 ng/mL, and thereafter to 11 ng/mL. Repeat imaging showed that the tumor had decreased in size. Approximately three months after completion of the last cycle of chemotherapy the patient underwent retroperitoneal tumor resection, along with partial small bowel resection. There was no evidence of malignancy in the final surgical pathology. One year later he is cancer free.

DISCUSSION:
This case highlights a successful collaboration between gastroenterology, radiology, surgery and oncology. There are no randomized trials in the treatment of retroperitoneal GCTs, thus case reports such as this provide much needed guidance in the treatment of this rare condition. It also illustrates the importance of tissue diagnosis via EGD in order to provide prompt diagnosis without invasive surgical biopsy.
2534 Clinical Pearls in Current Diagnosis and Management of Salmonella paratyphi Infection
Authors: Hershman Melissa , Kambo Varinder 
Published: October 2019

INTRODUCTION:
Typhoid and paratyphoid infections are rarely encountered in the United States, though are a major contributor to disease in developing countries. Growing virulence of organisms and lack of effective paratyphoid vaccination yield major public health concerns. We present two related individuals with typical symptoms of infection at varied presentation intervals.

CASE DESCRIPTION/METHODS:
A 31-year-old previously healthy female presented with four days of weakness, fevers, nausea, vomiting, and non-bloody diarrhea. She traveled to Pakistan two weeks prior. Admission examination was significant for fever of 100.5°F, hypotension, dry mucous membranes, ill appearance, and diffuse abdominal pain. Laboratory tests revealed white blood cell count 6.5 K/uL, hypoalbuminemia of 3.3 g/dL, alkaline phosphatase 178 U/L, AST 151 U/L, alanine aminotransferase ALT 130 U/L. Abdominal CT demonstrated terminal ileitis with right lower quadrant mesenteric lymphadenopathy up to 1.3 cm (Figure 1). Admission blood cultures grew SalmonellaParatyphi in both aerobic and anaerobic bottles, yet stool cultures remained negative on a second repeated sample. The laboratory reported sensitivity to ampicillin, ceftriaxone, ciprofloxacin and trimethoprim/sulfamethoxazole. However, additional requested sensitivity testing found nalidixic acid resistance, and minimum inhibitory concentration (MIC) of 1 to ciprofloxacin. The husband of the patient above, a 27-year-old male, presented two weeks after the discharge of his wife. He reported fever and chills for five days, with later abdominal cramping and diarrhea. On admission, white blood cell count was 4.9 K/uL with 19% bands, and liver function tests mildly elevated (AST 68 U/L, ALT 72 U/L). One of four blood culture bottles grew Salmonella Paratyphi with equivalent sensitivities. Two stool sample cultures were negative for Salmonella or enteric pathogen. Both patients completed two weeks of oral antibiotics with trimethoprim-sulfamethoxazole and did well subsequently.

DISCUSSION:
Our cases highlight diagnostic pearls of this condition including relative bradycardia after restoring hydration, leukopenia, transaminitis and ileitis. We demonstrate the utility of blood cultures, and how negative stool cultures may lead to false reassurance. Antibiotic resistance with Salmonella is challenging, particularly if providers are unaware of minimum inhibitory concentration cut-offs before selecting conventional fluoroquinolone therapy.
2535 Localized AL-Type Intestinal Amyloidosis Presenting as Refractory Iron Deficiency Anemia and Right Lower Quadrant Abdominal Pain
Authors: Kassim Gassan , Bsrat Makda , Rastogi Neelesh , Atluri Srilakshmi , Smith Michael S. 
Published: October 2019

INTRODUCTION:
Amyloidosis is characterized by extracellular deposition of abnormally folded proteins creating insoluble fibrils, which disrupt tissue structure and function. Amyloidosis can be either systemic or localized. Localized amyloidosis is defined by the production of precursor proteins in the same location as amyloid deposition. We present a case of biopsy-proven localized AL intestinal amyloidosis.

CASE DESCRIPTION/METHODS:
A 91-year-old female with a past medical history significant for hypertension and iron deficiency anemia not improving with oral iron presented with progressively worsening dyspnea on minimal exertion, with diffuse weakness and fatigue. She denied any NSAID use. Hemoglobin on admission was 3.8 g/dL, improving to 6.4 g/dL after transfusion of 3 units of packed red blood cells. Upper endoscopy showed very friable mucosa with contact bleeding in the duodenum, along with patchy areas of abnormal mucosa in the 2nd portion (Figure 1). Duodenal biopsies were consistent with amyloidosis based on Congo red and crystal violet stains. Liquid chromatography tandem mass spectrometry was performed on peptides extracted from the specimen and indicated AL (lambda)-type amyloid deposition. Cardiac MRI showed no evidence of infiltrative heart disease or amyloid deposition. Bone survey showed no lytic lesion, and a marrow biopsy showed no morphologic evidence of plasma cell neoplasm with normal karyotype. Urine immunofixation electrophoresis showed no abnormalities. Urine and serum protein electrophoresis showed no monoclonal protein. With no evidence of systemic amyloidosis, diagnosis of localized intestinal amyloidosis was made. No systemic therapy was indicated. Patient was treated with IV iron transfusions. At a subsequent admission, she presented with subacute right lower quadrant pain. CT abdomen/pelvis with oral and intravenous contrast showed thickening of the distal small bowel with shouldering (Figure 2). Lesion was presumed to be secondary to intestinal amyloidosis. Patient refused further invasive interventions.

DISCUSSION:
Localized AL-type intestinal amyloidosis is rarely diagnosed. Common symptoms are non-specific and can include erosion, ulceration, bleeding, malabsorption, intractable diarrhea, obstruction or ischemia. This patient presented with recurrent symptomatic iron deficiency anemia refractory to oral iron repletion. Intestinal amyloidosis should be considered in similar presentations.