bluuebunny/crossref_metadata_2025_split huggingface dataset:
2529 A Case of Cytomegalovirus Causing Duodeno-Colonic Fistula in Immune Competent Patient
Authors: Myadam Rahul , Zafar Yousaf , Jamil Laith H. 
Published: October 2019

INTRODUCTION:
Cytomegalovirus (CMV) is a common opportunistic infection in immune compromised patients. Within the gastro-intestinal tract, it is a known cause of esophagitis and colitis. A rare presentation of CMV infection is an enteric fistula with only a few cases reported. We present a case of duodena-colonic fistula secondary to CMV in an immune competent host.

CASE DESCRIPTION/METHODS:
86-year gentleman with past medical history of dementia who presented with complaints of feeling tired, jaundice and colorless diarrhea, significant weight loss for two months. He denied alcohol use and was not taking any prescription medications. He denied family history of cancer or liver disease. His initial labs showed non-specific elevation in the liver enzymes along with mild anemia. He underwent an MRI abdomen that showed duodenal swelling but no obstructive mass or bile duct dilation. Endoscopic ultrasound showed a large duodenal ulcer with duodena-colonic fistula that was large enough for the scope to pass through. Biopsies were taken from the fistula and liver which showed cytoplasmic inclusion bodies characteristic of CMV. HIV antibodies were negative and CMV blood titres were elevated. His acute liver injury was attributed to CMV hepatitis. He completed 6 weeks of anti-viral treatment with ganciclovir. A repeat endoscopy 2 months later showed healing duodenal ulcer with no fistula present. Blood CMV level was negative at the time of completion of anti-viral treatment. He was seen later in the immunology clinic to evaluate why he had such a severe infection from CMV. His labs were significant for only mildly reduced B lymphocyte count – 47 (normal 100-700) with slightly lower immunoglobulin G level 748 (normal 762-1488) and immunoglobulin M level 25 (normal 38-328). Rest of the labs were unremarkable including a complete blood picture, lymphocyte subsets and lymphocyte proliferation studies. It was felt that his CMV infection was isolated and because he had no recurrent infections it was decided by the patient and the immunologist to forego any further investigations of immune deficiency.

DISCUSSION:
In clinical practice, it is important to exclude CMV infection as a cause of intestinal ulcers even in immune competent patients. Especially if they are accompanied by an enteric fistula. Treatment of the CMV enteric fistula involves both anti-viral therapy and surgical closure of the fistula. Rarely such as in our patient, healing of the fistula can take place without any invasive procedures.
2530 An Unusual Cause of Abdominal Pain From Salmonella enteritidis (SE): Guess Where the Bug Was?
Authors: Melki Gabriel , Laham Linda , Karim Gres , Komal Fnu , Barham Shaker , Yuridullah Ruhin , Vora Aarohi , Sultana Yasmeen , Baddoura Walid 
Published: October 2019

INTRODUCTION:
Aortitis, an inflammatory entity with high mortality that is usually due to a rheumatologic etiology; however, an infectious etiology is sometimes the cause. We present a rare case of aortitis secondary to Salmonella septicemia treated with 6 weeks of antibiotics. Endovascular surgical repair (EVAR) with antibiotics (abx) is the preferred treatment.

CASE DESCRIPTION/METHODS:
A 76 year-old male with HTN, DM and CAD s/p CABG 3 months prior, presented to the ED c/o 7-day hx of suprapubic abdominal pain radiating to the lower quadrants and lower back, associated with fever, chills, night sweats, and chest pain. There was no recent history of a diarrheal illness. VS: T 101 F, BP 100/60, RR 18 and pulse of 100. PE revealed costochondral erythema and tenderness, as well as manubrial and suprapubic tenderness. Labs showed WBC 31000, ESR 100, CRP 150, CT abdomen revealed perineural fibrosis of the aorta just above the ostium of the IMA; the presence of air pockets was concerning for infectious aortitis. Patient refused surgery. Blood C&S were sent and patient was started on IV Cefipime, Linezolid and metronidazole. Sternal osteomyelitis was suspected. Bone scan revealed increased uptake in the region of the manubrium and upper body of the sternum. CTA confirmed aortitis. Blood C&S and sternal biopsy grew SE and abx were switched to IV ceftriaxone for 6 weeks. There was clinical and radiographic improvement without complications.

DISCUSSION:
Salmonella aortitis carries a high mortality even with best treatment options, making prompt diagnosis crucial for survival. Risk factors for Salmonella aortitis include vascular pathologies, CAD, HTN, DM, immunosuppression, seronegative C2 Infections, rheumatological diseases and hematological malignancies. The best treatment for infectious aortitis is EVAR with long-term abx. Treatment with abx alone is controversial; however, their use is the mainstay of therapy. Review of literature revealed that patients treated solely with abx without surgery did not survive. Duration of abx is also controversial with some experts suggesting lifelong treatment. In this case, the patient refused surgery and received abx for 6 weeks only, with resultant clinical and radiological remission.
2536 Celiac Disease Presenting With Duodenal Ulcerations and Small Bowel Intussusception
Authors: Samuel Ronald , Bhatt Asmeen , Bilal Mohammad , Luthra Gurinder 
Published: October 2019

INTRODUCTION:
Celiac disease is an autoimmune disorder that is triggered by gluten causing villous atrophy in the small intestine. Patients with celiac disease can present with a wide range of symptoms. We present a unique case of celiac disease presenting with duodenal ulcerations and small bowel intussusceptions.

CASE DESCRIPTION/METHODS:
A 60-year-old male with past history of stage I colon cancer status post partial colectomy 8 years ago presented with diarrhea and weight loss. The patient reported profuse diarrhea accompanied by a 20 lbs. weight loss that started six months ago. He denied other symptoms. His prior colonoscopies 1 year and 4 years after the partial colectomy were unremarkable. Physical examination was unremarkable. Laboratory data including hemoglobin was normal. Stool studies including infectious work up (clostridium difficile, stool cultures, ova and parasites) and fecal calprotectin were normal. A computed tomography (CT) scan of the abdomen and pelvis showed small bowel intussusception, mesenteric lymphadenopathy, and absence of any metastatic disease in the abdomen or pelvis (Figures a and b). A push enteroscopy was performed and revealed multiple scattered superficial ulcerations throughout the duodenum from the bulb to the third portion (Figures c and d). Repeat colonoscopy was unremarkable. Duodenal biopsies showed marked villous blunting, crypt hyperplasia and increased intraepithelial lymphocytes (Figures e and f) consistent with Celiac disease (Marsh 3b criteria). Blood was checked for celiac disease serologies and showed an elevated Anti-Tissue Transglutaminase IgA Antibody and a Deaminated Gliadin Peptide IgA Antibody. The patient was advised to start a gluten free diet. Four months after diagnosis, and being on a gluten-free diet, the patient had complete resolution of diarrhea and regained 20 lbs. of weight.

DISCUSSION:
Celiac disease can present with a variety of symptoms including diarrhea, nutritional deficiencies, weight loss, and gastric distension. Duodenal ulcerations and small bowel intussusception are exceedingly rare presentations of celiac disease. Even though these presentations have been previously been described separately, but they have not been reported together in an adult patient. Our case highlights that gastroenterologists should bear in mind the differential diagnosis of celiac disease in patients with small bowel intussusception, even in adults.
2538 Severe Protein-Losing Enteropathy and CMV Duodenitis in an Immunocompetent Male
Authors: Nhu Quan M. , Hai Faizi , Konijeti Gauree G. 
Published: October 2019

INTRODUCTION:
Cytomegalovirus (CMV) infection, typically associated with immunodeficiency, has been reported to also occur in immunocompetent patients. CMV infection of the gastrointestinal (GI) tract is uncommon in immunocompetent hosts and typically involves the lower GI tract. We encountered a case of CMV duodenitis associated with severe protein-losing enteropathy in an otherwise healthy male.

CASE DESCRIPTION/METHODS:
A 27-year-old man with a 2-year history of mild, intermittent non-bloody diarrhea presented with 2 weeks of worsening diarrhea, epigastric pain, nausea, vomiting and poor oral tolerance. His only medication was emtricitabine/tenofovir for HIV pre-exposure prophylaxis, initiated 4 months prior to presentation. Physical examination revealed a tender epigastrium and anasarca. Laboratory evaluation showed WBC 13.2 K/mcL (12.2% monocytes), albumin 1.9 g/dL, AST 64 U/L, ALT 77 U/L, total bilirubin 1.0 mg/dL, INR 1.0, and lipase 346 U/L. Serum HIV antigen/antibody was negative, and CD4 cell count was 873 cells/mcL. Urinalysis was unremarkable and was without proteinuria. Stool studies were negative for common enteric bacterial pathogens, Clostridium difficile, Giardia, and ova/parasites. Fecal calprotectin was elevated at 390 µg/g. MRI/MRCP imaging of the abdomen and pelvis showed a thickened duodenum, and peripancreatic fat stranding and fluid (suggestive of acute pancreatitis), without biliary or pancreatic duct dilation. EGD showed severe duodenitis with diffuse erythema, mucosal denudation, patchy erosions, and nonbleeding ulcerations. Biopsy with immunostain revealed CMV duodenitis. Serum CMV DNA was mildly elevated at 142 IU/mL. Following multidisciplinary discussion, supportive care was provided without antiviral therapy. Over the next month, the patient improved clinically, with normalization of serum albumin, transaminases, and CMV titer.

DISCUSSION:
Several reports have described tissue invasive CMV infection in immunocompetent patients, primarily involving the colon. CMV duodenitis and pancreatitis are rare, even in immunocompromised patients. Our case describes a healthy man with severe CMV duodenitis resulting in protein-losing enteropathy. CMV likely caused mild acute pancreatitis in our patient as well. A recent systematic review did not support antiviral therapy for immunocompetent patients with CMV. Supportive care with close monitoring may be sufficient; however, further investigation is needed to routinely support this practice.
2540 An Exceptionally Rare Cause of Abdominal Pain: Protein C Deficiency-Induced Mesenteric Panniculitis
Authors: Alomari Mohammad , Hader Ismail , Al Momani Laith , El Kurdi Bara , Young Mark 
Published: October 2019

INTRODUCTION:
Mesenteric panniculitis (MP) is a rare benign disorder that affects the intestinal mesentery causing unexplained gastrointestinal complaints. Herein, we present a case of MP-induced by microinfarction due to Protein C deficiency.

CASE DESCRIPTION/METHODS:
A 46-year-old female patient with a significant medical history of protein C deficiency and recurrent deep vein thrombosis on long term anticoagulation with warfarin presented to the emergency department after a syncopal episode. She suffered from persistent nausea, vomiting, inability to tolerate oral intake, and mild abdominal pain for the last two weeks prior to presentation. Physical examination was mostly unremarkable except for mild periumbilical tenderness and orthostatic hypotension. Laboratory testing revealed a white blood count of 8 K/uL, hemoglobin of 14.9 g/dL, serum sodium of 135 mmol/L, serum potassium of 4.1 mmol/L, blood urea nitrogen of 20 mg/dL, creatinine of 1.0 mg/dL, international normalized ratio (INR) of 1.23, D-Dimer of 1221 ng/mL, C-reactive protein of 20 mg/L, and erythrocyte sedimentation rate of 29 mm/hr. Contrast-enhanced computed tomography (CT) of the chest and abdomen was negative for thromboembolism, however, it showed a hazy, misty appearance of the mesentery with multiple prominent lymph nodes. The patient was treated conservatively; warfarin was resumed with heparin bridging. With clinical improvement, the patient was discharged home.

DISCUSSION:
MP is a benign fibroinflammatory disorder primarily affecting the adipose tissue of the mesentery with a prevalence range between 0.16-0.6%. It typically occurs in the 6th decade of life with a male to female ratio of 2:1. The underlying etiology of MP remains unclear, history of abdominal surgery and trauma were considered predisposing factors in the majority of the cases, in addition to autoimmune disorders and vasculitis. Clinical presentation varies with most of the cases being typically asymptomatic. Symptomatic patients report nonspecific complaints such as abdominal pain, fever, nausea, and fatigue. Physical examination and laboratory workup are usually nonrevealing but palpable masses have been reported. These factors make the diagnosis even more challenging and usually requires a contrast-enhanced CT scan. Hence, high clinical suspicion is required to diagnose MP while investigating otherwise unexplained abdominal pain.
2541 Cryptosporidial Colonization of a Peptic Ulcer in a Healthy Patient—Random Occurrence or a Risk Factor?
Authors: Amarnath Shivantha , El Imad Cheikh Talal , Kingsley Ebare , Wu Hueizhi , Mulrooney Stephen 
Published: October 2019

INTRODUCTION:
The incidence of Cryptosporidial enteritis (CE) has recently risen in the USA due to water and foodborne outbreaks. It has a self-limited course in healthy hosts. We describe a case of a healthy female with history of gastric bypass surgery who presented with a one-month history of voluminous watery diarrhea and vomiting. This was a rare case of CE diagnosed by endoscopic biopsies of two anastomotic peptic ulcers that were colonized by Cryptosporidium spp.

CASE DESCRIPTION/METHODS:
57-year-old female with a history of GERD, iron deficiency anemia, and Roux-en-y gastric bypass complicated by jejunal strictures with revision of the gastro-jejunal anastomosis, presented with a 7-day history of vomiting and crampy epigastric abdominal pain. She recently returned from a two-week vacation to Latin America. Upon arrival, she experienced progressively worsening voluminous watery diarrhea associated with intermittent melanotic stools followed by frequent episodes of non-bilious, non-bloody vomiting along with reduced oral intake. Abdominal exam revealed hyperactive bowel sounds with tenderness to deep palpation of the epigastrium. Her hemoglobin dropped from a baseline of 11.2 g/dL to 9.1 g/dL. CT scan of the abdomen with contrast showed inflammation around the gastro-jejunostomy site. Blood and stool cultures were negative. Upper endoscopy revealed a 1 cm and 2 cm clean-based ulcers with a deep crater at the anastomotic site. Biopsy demonstrated spherical bluish-purple organisms, 2-5 µm in diameter on hematoxylin and eosin, Gomori Methanamine Silver Nitrate and Masson's trichrome stains. They were suggestive of Cryptosporidium, and the patient was diagnosed with CE. Patient's immunodeficiency workup was unremarkable. Patient's symptoms resolved with a three-day course of Nitazoxanide 500 mg twice per day.

DISCUSSION:
CE is a significant cause of chronic diarrhea in both healthy and immune-compromised individuals, thus stands as a key differential in those presenting with persistent voluminous diarrhea. The modified acid-fast stain carries only 50% sensitivity to this protozoan, and diagnosis is often missed on routine stool ova and parasite tests. Novel diagnostic modalities have proven useful in identifying this protozoan in stool samples. We report the first case documenting Cryptosporidium colonization of anastomotic site peptic ulcers with complete resolution of symptoms following a short course of Nitazoxanide.
2545 If Any Doubt, Rule It Out: Having a High Clinical Suspicion for Paraduodenal Hernia
Authors: John Jason J. , John Elizabeth S. , Tarnasky Paul 
Published: October 2019

INTRODUCTION:
Paraduodenal hernia (PDH) is a type of internal abdominal hernia (IH), a rare entity with a reported incidence of 0.2-0.9% on autopsy. Though typically asymptomatic, it is an important diagnosis to consider when suspicious for bowel obstruction as mortality can reach up to 20%. We report a case of a 46 year old female with vague abdominal complaints who had a PDH.

CASE DESCRIPTION/METHODS:
A 46 year old female with a history of questionable bowel obstruction and hysterectomy, presented with 3 days of abdominal pain, nausea, and vomiting. She had decreased stool caliber over the previous week with no bowel movements, and inability to pass gas for 2 days. The patient reported having a similar episode 2 years prior that resolved with nasogastric tube decompression. Imaging was unrevealing and an etiology for her symptoms was not identified. On admission, her vitals were stable and her physical exam was positive for abdominal distention, high-pitched bowel sounds, and tenderness to palpation in the right upper quadrant. Labs were remarkable for leukocytosis with a WBC of 13.6. CT abdomen/pelvis with contrast revealed an internal hernia with small bowel and mesentery extending lateral to the right colon through a defect in the ascending mesocolon (Figure 1). The patient's symptoms persisted so she was taken to the operating room for a diagnostic laparoscopy. A PDH was repaired, and her symptoms subsequently improved.

DISCUSSION:
PDH is rare and difficult to diagnose, but is an important entity to consider in bowel obstruction. Though responsible for bowel obstruction in 5.8% of patients, early diagnosis is crucial as there is an overall 20% mortality rate, 50% mortality if the bowel is strangulated, or nearly 100% if ischemic. The etiology of PDH is widely debated, but the most accepted theory is an error in intestinal rotation and fixation causing entrapment of the small bowel between the mesocolon and posterior abdominal walls. In adolescents, it is thought to arise from congenital defects. In adults, the major risk factor is prior surgical intervention, including Roux en Y bypass, peripheral adhesive bands, laparoscopic surgeries, or gynecologic surgeries. Clinical diagnosis of PDH is extremely challenging as abdominal exams and radiologic studies are subtle or negative until patient becomes acutely ill. Compared to other IHs, symptoms and radiologic findings in PDHs may be particularly subtle. Having a high clinical suspicion is crucial given high mortality rate of complications.
2546 Rare Case of Duodenal Melanosis in a 72-Year-Old Male
Authors: Rana Navpreet , Minhas Umair , Mahl Thomas 
Published: October 2019

INTRODUCTION:
Pseudomelanosis (PM) is a rare condition of unknown etiology. Prevalence of this condition is not well documented however, there have been several case reports. It is described as speckled black pigmentation of intestinal mucosa. Underlying pathogenesis and significance of PM is not well understood. Reports have associated it with medications, including anti-hypertensives and iron supplements and systemic diseases such as chronic renal disease, iron deficiency and diabetes mellitus. It is most commonly discovered as an incidental finding during endoscopy and frequently seen in the duodenum, however, few cases have also reported it in the stomach and jejunum.

CASE DESCRIPTION/METHODS:
A 72-year-old male with multiple co-morbidities including diabetes, hypertension, peripheral arterial disease and chronic kidney disease presented with epigastric pain, nausea and hematemesis. There was no melena or hematochezia. Last colonoscopy 10-years ago was significant for diverticulosis and hemorrhoids. His home medications included aspirin, clopidogrel, amlodipine, hydralazine, hydrochlorothiazide, atorvastatin, levothyroxine, furosemide and baclofen. On evaluation, digital rectal exam was significant for dark stools and hemoglobin decrease from 11.4 to 9.2 over 8 months. Upper endoscopy showed normal appearing esophagus and gastric mucosa. Dark pigmentation of the duodenal mucosa was noted and biopsied. Pathology findings were consistent with intestinal pseudomelanosis. Patient's symptoms resolved without any additional intervention. He was discharged on pantoprazole and continued on aspirin, but his clopidogrel was discontinued.

DISCUSSION:
Prognosis of PM is not well understood, but it is considered a benign condition. Unlike melanosis coli, which is a similar finding of black/brown speckles in the colon that has been associated with colon cancer. Histochemical studies have shown the pigments found in PM are likely secondary to accumulation of iron sulfide, ferrous sulfate or lipomenin within the lysosomes of macrophages in lamina propria of small intestine. Current theories suggest PM develops secondary to impaired iron transport coupled with sulfur from anti-hypertensive medications. In our patient, his medical conditions and anti-hypertensive medications likely contributed to this benign finding. Although, considered a benign condition, it is imperative to identify this condition during endoscopy to exclude other serious conditions.
2548 Jejunal Perforation: A Very Rare Presentation of Jejunal Adenocarcinoma
Authors: Gill Jasmeet , Sannapaneni Shilpa , Feldman Mark 
Published: October 2019

INTRODUCTION:
Small bowel malignancies constitute less than 5% of all gastrointestinal malignancies. The most common histological types of small bowel cancer are adenocarcinoma, neuroendocrine cancer, lymphoma and sarcoma. Adenocarcinoma represents 25-40% of primary small bowel malignancies, with the highest incidence in the duodenum and the incidence progressively decreasing down the small intestine.

CASE DESCRIPTION/METHODS:
A 69 year old previously healthy women presented with periumbilical pain for four weeks. She also reported early satiety but no weight loss. The night prior to presentation abdominal pain became severe with one episode of vomiting. There was no history of chronic NSAIDs use. She had a 40 pack-years smoking history. She had two cesarean sections and a total abdominal hysterectomy with bilateral salpingo-opherectomy. She did not have routine colorectal cancer screening. On abdominal examination she had a distended abdomen and mild periumbilical tenderness. Laboratory testing revealed leukocytosis of 15000/µL and a hemoglobin level of 10.2 g/dl with a low MCV 78.6 fl. Noncontrast CT of the abdomen showed wall thickening and focal perforation in a loop of jejunum. There was no bowel obstruction and no free intraperitoneal air seen. Exploratory laparotomy revealed a large inflammatory mass in the proximal jejunum densely adherent to the mid-transverse colon. There was a large perforation (3.5 cm of greatest dimension) of a jejunal mass. The mucosa surrounding the defect was hyperemic and thickened. Microscopic examination showed a well-differentiated adenocarcinoma invading into muscularis propria. There was no lymphovascular invasion and no metastasis were identified in 13 excised regional lymph nodes. Immunostains were negative for cytokeratin 7 (expressed in lung and pancreatic adenocarcinomas), focally positive for cytokeratin 20 (colorectal adenocarcinoma) and were positive for CDX2. CDX2 is a highly sensitive and specific marker of adenocarcinoma of intestinal origin.

DISCUSSION:
Jejunal adenocarcinoma is an extremely rare GI malignancy. The clinical presentation is often with abdominal pain and distension; only 10% present as a bowel perforation. Surgical resection is considered curative treatment for localized adenocarcinoma. Oxaliplatin-based adjuvant chemotherapy is suggested for patients with lymphovascular invasion. In our patient perforation per se was considered a high-risk feature and the patient was advised to have post-operative adjuvant chemotherapy.