bluuebunny/crossref_metadata_2025_split huggingface dataset:
2085 Suspected Crohn’s in Acute Salmonella Enterocolitis: A Journey of Differentiating Two Common Terminal Ileitis Etiologies
Authors: Kim Alex , Noverati Nicholas , Feldman Andrew , Akhtar Nabeel , Duca Nicholas 
Published: October 2019

INTRODUCTION:
Terminal ileitis signifies a generalized inflammatory process in the most distal portion of the small bowel, with an expansive range of underlying etiologies including Crohn’s disease and salmonella. Although stool cultures may reveal a salmonella infection, the diagnosis becomes more difficult if stool cultures are positive but patients do not respond to antibiotics. Treating such pathology with two potential underlying etiologies may lead to further complications, specifically, when administering corticosteroids and immunotherapy for an autoimmune disorder may conflict with active treatment against an acute infection. Our case presents a patient who had known salmonella positive stool cultures but inconsistent colonoscopy and pathology results. He ultimately improved with steroid and anti-TNF therapy.

CASE DESCRIPTION/METHODS:
A 29-year-old male with history of small bowel obstruction of unclear etiology five months prior, presented with acute on chronic diarrhea and abdominal pain. He denied any recent sick contacts, ingestion of raw or undercooked food, or personal or family history of inflammatory bowel disease (IBD). A CT scan identified terminal ileitis. Stool cultures returned positive for salmonella. Despite treatment with ciprofloxacin, patient’s symptoms persisted. Colonoscopy revealed diffuse inflammation and ulceration of the terminal ileum without stricture, with extension into the ascending and transverse colon. Preliminary biopsy revealed reduction in goblet cells. The patient was treated with solumedrol and subsequent infliximab due to the high suspicion of underlying IBD pathology after receiving a course of antibiotics. Though his hospital course was complicated by partial small bowel obstruction, his symptoms ultimately resolved.

DISCUSSION:
Terminal ileitis secondary to Crohn’s disease and salmonella may overlap in presentation which can complicate therapy. In this case, it is probable that there was a component of IBD superimposed with a bacterial infection, given the acute on chronic nature of his symptoms. In the case of superimposed infection, antibiotics should be initiated prior to prescribing immunosuppressive therapy that could allow further invasion. However, waiting to initiate immunosuppressants must be balanced with a patient’s worsening clinical picture and complications such as small bowel obstruction.
2086 The Importance of Careful Appendiceal Inspection During Surveillance Colonoscopy in IBD Patients: A Case of Appendiceal Mucocele in an Ulcerative Colitis Patient
Authors: Horrigan Jamie , Leong Karissa , Calderone Jessica , Aldyab Mahmoud , Valerian Brian , Tadros Micheal , Casale Charles 
Published: October 2019

INTRODUCTION:
Appendiceal mucocele (AM) is a rare condition in which the appendix dilates and fills with mucus. These lesions can be benign or malignant and are classified into mucinous adenomas, low-grade appendiceal mucinous neoplasm (LAMN) and mucinous adenocarcinoma. Patients with inflammatory bowel disease (IBD) are at increased risk of colorectal neoplasia, but it is unknown whether IBD is associated with AM.

CASE DESCRIPTION/METHODS:
The patient is a 42-year-old female with a 24 year history of ulcerative colitis (UC) who presented with acute bloody diarrhea. She was diagnosed with UC at age 18, requiring treatment with cyclosporine and prednisone. She maintained steroid-free remission on mesalamine for 20 years before stopping treatment. She was clinically asymptomatic for 4 years until this acute flare. Colonoscopy revealed moderate to severe pancolitis with continuous and circumferential inflammation from the anus to cecum. A 2 cm × 1 cm submucosal mass was found within the appendix, concerning for AM or carcinoid tumor. CT showed appendiceal distention measuring up to 13 mm with a mucocele favored over chronic appendicitis due to the lack of periappendiceal edema. She was started on prednisone and mesalamine to improve the inflammation of the colon and decrease the risk of staple line dehiscence after surgery. Nearly 3 months later, the patient underwent an uncomplicated laparoscopic resection of the appendix and a partial cecectomy. Pathology revealed LAMN with negative margins.

DISCUSSION:
There is a low prevalence of primary appendiceal neoplasms and few reported cases of AM in IBD patients, the majority of which occurring in UC patients. Nevertheless, endoscopists should still be aware of the possible association between IBD and AM due to AM’s malignant potential. This abnormality can be subtle, so careful inspection of the appendix is warranted during routine colonoscopy. Rupture is a dangerous complication as intraperitoneal spread of malignant cells may lead to pseudomyxoma peritonei. Patients may present with right lower quadrant pain, abdominal mass, gastrointestinal bleeding, nausea, vomiting, weight loss and/or intussusception. Patients may also be asymptomatic with a bulging appendix incidentally found on colonoscopy. Diagnosis is further supported by CT or endoscopic ultrasound. Management is appendectomy with possible partial cecectomy or right hemicolectomy depending on tumor size, lymph node involvement, degree of atypia and IBD disease activity.
2087 Severe CMV Proctitis as the Initial Presentation of Ulcerative Proctitis
Authors: Arfeen Mohammad , Scott Brandon , Yarbrough Alex 
Published: October 2019

INTRODUCTION:
CMV colitis is seen in patients with IBD on long term immunosuppressive therapy; studies show the rate of seropositivity in IBD patients is the same as the general population (∼70%). Due to this there is a concern for reactivation when long term immunosuppressive therapy is initiated. Here we present the case of a patient who presented with CMV colitis prior to initiation of any therapy or diagnosis of IBD; CMV colitis in immunocompetent patients remains fairly rare.

CASE DESCRIPTION/METHODS:
A 30-year-old male with a history of EoE and PUD presented with seven days of painful hematochezia and constipation; he denied any fevers, however did have chills and cold sweats. He had no history of IVDA, intranasal drug use, anal sex, or risky sexual behaviors. His EoE symptoms were well controlled on PPI. Temperature was 103.2 F, he was tachycardic and tachypneic on presentation. CT revealed fecalization of the small bowel, significant stool burden, and rectal stool ball. He was started on lubiprostone and a bowel regimen with PEG-3350, he passed stool with significant decrease in abdominal distention, however he continued to have rectal pain and hematochezia. Colonoscopy was performed and showed diffuse severe inflammation with erythematous, granular, and friable mucosa in the rectum. He was started on rectal mesalamine and corticosteroid therapy. Biopsies returned showing CMV associated severe ulcerative proctitis without evidence of dysplasia. He was then started on ganciclovir and PICC was placed for 2 weeks of treatment. Repeat HIV and HIV viral load testing were done, both returning negative. On follow up in clinic he reported good control of his symptoms with oral and rectal mesalamine. Flexible sigmoidoscopy showed a rectal scar and significantly improved inflammation, biopsy revealed ulcerative proctitis.

DISCUSSION:
CMV colitis has been commonly associated with UC patients on immunosuppressive therapy. An increasing body of literature shows the presence of colonic CMV infection in patients with UC on therapy has been associated with decreased response to steroids and other immunosuppressive therapies. Prognosis is poor unless the infection is promptly identified and anti-viral therapy is started. It still remains a rare entity in immunocompetent patients. This raises the question if CMV testing should be done prior to initiation of immunosuppressive therapy in these patients and if CMV testing should be done regularly in patients with refractive UC flares.
2088 A Rare Case of Postoperative Recurrence of Crohn’s Disease Associated With Abdominal Actinomyces and Bacteremia
Authors: Khanna Tushar , Vielemeyer Ole , Rubin Moshe , Scherl Ellen J. 
Published: October 2019

INTRODUCTION:
We present a rare case of actinomyces bacteremia in a 27-year-old woman with fistulizing Crohn's ileocolitis who presented with acute abdominal pain in the setting of sepsis & microperforations 6 weeks after extensive bowel surgery.

CASE DESCRIPTION/METHODS:
The patient's Crohn's disease was diagnosed 10 years ago, treated initially with 6-MP, azathioprine, 5-ASA & later with biologics & steroids all of which provided minimal relief. Prior to undergoing surgery, she had daily complaints of RLQ abdominal pain with MRI suggestive of significant ileocolitis with fistulae. She underwent successful ileocolectomy & fistula stricturoplasties with remarkable improvement in symptoms in the 3 weeks post-op. However, 6 weeks post-op her condition worsened again with new onset of pain, fever, tachycardia, hypotension and imaging concerning for perforated bowel. She was thus readmitted with admission blood cultures revealing Actinomyces odontolyticus bacteremia. Abdominal CT showed possible small perivesicular fluid collection. Repeat blood cultures on antibiotics remained sterile & the patient was discharged on antibiotics. Local anaerobic cultures from the neo-terminal ileum on repeat colonoscopy with biopsy 6 weeks post-op were also found to be sterile, with no evidence of actinomyces on pathology indicating possible clearance of local infection on antibiotics.

DISCUSSION:
We describe an unusual complication of Crohn’s disease: abdominal Actinomyces infection presenting with bacteremia. Actinomyces spp. are anaerobic gram-positive bacilli, most commonly found as part of normal flora of the oral cavity; it can also colonize the pharynx, other parts of the GI tract, GU system and the skin. It becomes virulent if introduced into deeper tissues through disruption of mucosal surfaces. Actinomyces often mimics other intra-abdominal conditions such as Crohn’s through the formation of fistulas & sinus tracts. The patient’s postoperative Crohn’s recurrence at the neo-terminal ileum confirmed on imaging paired with positive blood cultures in the setting of sepsis, raises a strong suspicion of infection due to Actinomyces spp. as the cause for worsening Crohn’s disease. This case suggests that abdominal actinomyces infection can be an unusual complication of Crohn’s disease and presents a diagnostic dilemma for clinicians given overlapping clinical & imaging findings. Gram stain and anaerobic culture remain the gold standard for the diagnosis of actinomyces & penicillin is usually the treatment of choice.
2089 Psoriasis Induced by Infliximab Treatment in a Young Patient With Crohn’s Disease
Authors: Shahid Rizwan , Singhania Rohit , Gupta Kamesh , Knox Spencer C. 
Published: October 2019

INTRODUCTION:
Now that Infliximab has been used more frequently for treatment of multiple autoimmune diseases including IBD, side effect profile of infliximab has increasingly been seen in clinical practice. One of the rare side effect is induction of psoriasis with infliximab though paradoxically it has been used as a treatment in psoriasis. We present a case of young female with Crohn’s who developed palmoplantar psoriasis while on infliximab.

CASE DESCRIPTION/METHODS:
30 Y/O female with history of Crohn’s s/p ileocecectomy (diagnosed in 2016 and subsequently lost to follow up), presented to GI clinic for ongoing diarrhea and abdominal pain for 2 months. She underwent elective colonoscopy which showed typical Crohn's appearance with endoscopic Rutgeerts Score of I3. She was started on infliximab and azathioprine after pretreatment testing. Three months into the treatment, she developed a new papular rash limited to her palms and soles which progressed to dry, erythematous rash with sloughing. She was diagnosed of drug induced psoriasis by dermatology and was started on topical petroleum based therapies and oral steroids. She showed no improvement in next few weeks and in fact, developed a new scalp rash. At this point, decision was made to stop Infliximab and start her on Stelara. Her rash started improving significantly after making this change and her bowel symptoms continued to be well controlled as well.

DISCUSSION:
TNF alpha inhibitors are currently the mainstay therapy for treatment of moderate to severe Crohn’s disease. TNF-a induced psoriasis is a major challenge for treating clinician. Prevalence of Psoriasiform lesions range from 1.7 to 35% in different studies. Its mechanism of action is unclear but it could be due to unopposed production of Interferon-A caused by TNF-a inhibitors as IFN-a is a well known trigger for development of psoriasiform lesions. First step in management includes topical therapies and oral steroids directed at controlling skin disease. If this fails, some studies suggest use of another TNF-a inhibitor though there is cross reactivity among different members of the class. Availability of Interleukin 12/23 inhibitors like Ustekinumab (Stelara) is an excellent alternative for such Crohn’s patients as it is also approved for psoriasis. We used this strategy in our patient who showed clinical improvement very quickly. There is certainly need of further analysis and studies to understand long term consequences of this approach as experience is still insufficient on this.
2092 A Rare Case of Primary Colonic Lymphoma Mimicking Metastatic Adenocarcinoma in a Patient With Ulcerative Colitis
Authors: Mavuram Meher S. , Maruvada Smita , Rashid Shazia , Hafiz Nazar , Chaudoir Catherine , Saire mendoza Mardeli , Samant Hrishikesh , Morris James D. 
Published: October 2019

INTRODUCTION:
Primary colorectal lymphoma (PCL) is uncommon and accounts for only 0.2-1% of all large intestine cancers. There is an increasing incidence in populations with Inflammatory bowel disease (IBD), Celiac disease, H. pylori and other autoimmune conditions. Here, we present a rare case of Ulcerative Colitis with primary Diffuse Large B Cell lymphoma (DLBCL) and liver metastasis.

CASE DESCRIPTION/METHODS:
Our patient is a 50 y/o male with left-sided ulcerative colitis presenting with a two- month history of severe left lower quadrant abdominal pain and constipation, without overt GI bleeding, diarrhea or weight loss. Examination was remarkable for left lower quadrant tenderness, without palpable mass. CT scan revealed multiple ill-defined liver masses concerning for metastasis with circumferential thickening in sigmoid colon with fat infiltration. Of note, patient had surveillance colonoscopy, few months prior to presentation which revealed marked erythema in the sigmoid colon, biopsies revealed acute on chronic inflammation without evidence of malignancy. Labs with normal CEA, AFP, CA 19- 9 levels. Repeat colonoscopy showed an ulcerated stricture with friable nodular mucosa in the sigmoid colon that was again biopsied in conjunction with biopsy of the liver lesions. Immunohistochemical staining of colon and liver lesions was positive for CD20 and negative for CK20, CK7 and CDX2, consistent with DLBCL. Patient was started on R-CHOP chemotherapy and is currently being monitored for response by Oncology.

DISCUSSION:
The risk of colorectal cancer significantly increases in IBD and surveillance is usually warranted. Although the suspicion of adenocarcinoma remains high in a UC patient with colonic mass and liver metastasis, PCL should also remain in the differential as correct pre-operative identification is crucial for the design of treatment. PCL is rare, with a male predominance in age 50-70 years and typically present with abdominal pain, lower GI bleeding, weight loss, palpable mass and rarely bowel obstruction. Diagnosis is aided by tissue biopsy and imaging. Multimodality approach involving both surgery and chemotherapy is the principal mode of treatment with radiotherapy in selected cases. Considering our patient’s clinical scenario, further speculations in routine CT scans to evaluate symptoms, alongside endoscopic surveillance for colorectal cancer in IBD, needs to be addressed.
2099 E. coli Sepsis Following FMT in an IgA Deficient IBD Subject
Authors: Glover Sarah C. , Burstiner Shane , Jones Demarre , Teymoorian Arian , Naga Yehia , Silver Jared , Pallav Kumar 
Published: October 2019

INTRODUCTION:
Fecal microbiota transplant (FMT) has been demonstrated to be an effective treatment option for recurrent C. difficile infections (RCDI) with minimal serious adverse reactions reported. Although the results of FMT for RCDI are promising, the screening process (for both donors and recipients) remains largely unregulated by the FDA.

CASE DESCRIPTION/METHODS:
A 19 y.o. male with a history of primary IgA deficiency, growth hormone deficiency, asthma, and ulcerative colitis presented to his gastroenterologist with his 3rd C. difficile infection in a 4 month period. FMT was performed via colonoscopy using commercially sourced stool. 10 days later, the patient presented to the ER with explosive bloody diarrhea, up to 20 BMs per day. He was also positive for leukocytopenia, tachycardia, intermittent subjective fevers, chills, night sweats, and abdominal cramping. Stool studies were positive for EPEC, ETEC, and Shiga toxin-producing E. coliO157:H7. Patient was not given antibiotics and received supportive care for 17 days until discharge. He has a good prognosis and has not experienced a recurrence of CDI since the FMT 3 months ago. Unbeknownst to his Gastroenterologist, the patient had a history of mostly asymptomatic, total primary IgA deficiency that was diagnosed in the Czech Republic.

DISCUSSION:
This appears to be the first reported instance of an individual with Primary IgA Deficiency undergoing FMT and also the first reported instance of FMT-introduced E. coli O157:H7 infection. The patient’s complete lack of IgA appears to be the main catalyst for his disastrous response to FMT. While barrier defects secondary to IBD and the concomitant use of immunosuppressive medications (Xeljanz and Entyvio) can increase susceptibility to infections, studies have shown FMT does not carry an increased risk of serious adverse effects in immunocompromised patients (including IBD patients on immunosuppressive therapy). This patient was not screened for immunodeficiencies prior to receiving FMT. The FDA has issued guidelines, but does not currently mandate which pathogens the stool must be screened for, or which comorbidities the recipient must be screened for. Given the understood importance of IgA in mucosal immunity against E. coli, and the outcome presented in this study, we suggest that rigorous screening of the recipient's medical history for immunodeficiency, and/or potentially running a basic Immunoglobulin panel, should be considered prior to performing FMT.
2105 Below the Belt: Unsual Site of Aortitis in Crohn's Remission
Authors: Mishra Kajali , Naffouj Sandra , Kaur Nirmal 
Published: October 2019

INTRODUCTION:
Aortitis is inflammation of the vessel wall that results in luminal narrowing or vessel strictures. It can involve any part of the aorta. In patients with Crohn’s, the reported sites of aortic inflammation are aortic valve leaflets and aortic root, which can result in aortic insufficiency and aneurysmal dilation.

CASE DESCRIPTION/METHODS:
A 61-year-old female with stable Crohn’s disease presented with epigastric pain, non-bilious non-bloody emesis, and diarrhea. She discontinued Mesalamine 8 years ago. Laboratory studies revealed leukocytosis (12K) and erythrocyte sedimentation rate of 12. Computed Tomography showed fat deposition in the terminal ileum and cecum, mesenteric edema with new wall thickening and fat stranding of the abdominal aorta (AA) and left common iliac artery (CIA). CT angiography (CTA) revealed a 6 mm soft tissue ring around the infra-renal AA with moderate stenosis and extension into the left CIA, compatible with aortitis. Aortic biopsy was not performed given no signs of systemic vasculitis or giant cell arteritis. Infectious etiology was suspected; blood cultures, urinalysis, stool PCR, Clostridium-difficile, HIV, Syphilis, Hepatitis, QuantiFERON, Histoplasmosis, Blastomycosis, Yersinia-Enterocolitica PCR, Cryptococcal antigen, serologies for Lyme disease, Rickettsia, Coxiella, Brucella, Bartonella, and Chlamydia were all negative. Transthoracic echocardiogram showed no evidence of endocarditis. Rheumatologic workup was negative (ANA, RF, ANCAs, CRP, IgG subclasses). Systemic antibiotics were started given concern for infection but the patient did not clinically improve. Given lack of improvement on antibiotics, methylprednisolone was initiated. Repeat CTA showed persistent inflammation. Adalimumab was started with significant symptomatic improvement. At 6 month follow up the patient was asymptomatic and repeat CTA showed no evidence of inflammation.

DISCUSSION:
We present a rare case of infra-renal aortitis in a patient with stable Crohn’s disease. There is only one reported case of abdominal aortitis in a patient with Crohn’s, but that patient had severe fulminant disease. Our patient with Crohn’s in remission had nonspecific gastrointestinal symptoms (epigastric pain, emesis, diarrhea), and was found to have infra-renal aortitis. Aortitis carries a high risk of aortic rupture and thrombosis of small vessels. Early recognition is crucial, as immunosuppressive agents can be used to reduce the risk of life threatening clinical complications.