bluuebunny/crossref_metadata_2025_split huggingface dataset:
1588 A Case of Suspected Adalimumab-Induced Apoptotic Colonopathy
Authors: Rojas Patricia Guzman , Gonzaga Ernesto Robalino , Vergeli-Rojas Jeannette , Parikh Jignesh 
Published: October 2019

INTRODUCTION:
Adalimumab is an anti-TNFa monoclonal antibody used for the treatment of multiple autoimmune diseases including IBD. Although it has shown a great benefit minimizing the burden of symptoms, it carries multiple side effects such as headache, nausea, vomiting, abdominal pain, rash, gastrointestinal hemorrhage and even diverticulitis. We present a rare side effect associated to this immune modulator.

CASE DESCRIPTION/METHODS:
A 40-year-old female with a PMH of Crohn's disease presented for a routine visit to the GI clinic. The patient had been undergoing treatment with adalimumab for past eight months, with non-adherence to treatment. She reported one loose bowel movement per day but denied any tenesmus, urgency, abdominal pain, bleeding or extra-intestinal manifestations. A follow-up colonoscopy showed a stricture in the ileo-cecal valve and a 0.5 centimeter aphthous ulcer in the ascending colon (Figure 1). Biopsies of the ileocecal valve and rectal area showed active chronic inflammation, while the ascending, transverse and descending colon showed inactive chronic colitis. Furthermore, the biopsy of the ileocecal and ascending colon revealed drug-induced apoptosis (Figure 2). She was switched to infliximab due to mentioned histopathological findings of apoptotic colopathy. She was also referred to colorectal surgery for evaluation of stricture and fistula formation.

DISCUSSION:
Apoptotic enteropathy describes a type of injury to the gastrointestinal mucosa, characterized by epithelial cell apoptosis. This characteristic histological feature can be caused by different etiologies like GI Graft versus host disease (GVHD), infections (CMV, adenovirus and cryptosporidiosis in AIDS patients) and drug induced injury. Medications linked to these histopathological changes are mainly immuno modulators: MMF, CTLA-4 inhibitors (ipilimumab), anti-PD-1 (nivolumab, pembrolizumab and avelumab), idelalisib, tumor necrosis alpha inhibitors (etanercept, infliximab) and anti-metabolites (methotrexate, capecitabine). Furthermore, there is only one case report elucidating the relation between adalimumab with apoptotic colopathy, which showed affectation of the right colon, being the same location of our patient's injury. We present this case to make physicians aware of this entity, since is an important feature to monitor in patients needing biologics. Furthermore, a repeated endoscopic evaluation should be done in order to assess resolution of pathology.
1592 Treatment of Severe Clostridioides difficile Infection With Intravenous Immunoglobulin
Authors: Park Connie , Chun Alexander 
Published: October 2019

INTRODUCTION:
Clostridioides difficile infection or C. diff (CDI) is the most common cause of health-care associated diarrhea. Despite interventions directed at decreasing transmission, the incidence of CDI remains high. Its morbidity, mortality, and overall burden on health care necessitate alternative therapies. As such, we report a case of severe CDI successfully treated with intravenous immunoglobulin (IVIG), a pooled blood product primarily used to treat antibody deficiencies or autoimmune diseases.

CASE DESCRIPTION/METHODS:
An 86-year-old female with diabetes and atrial fibrillation presented to our hospital with bloody stools. Her hospital course was long and complicated, requiring trials of multiple antibiotics: ceftriaxone, metronidazole, piperacillin-tazobactam, and ertapenem. One month into her hospitalization, she became septic with diarrhea and abdominal pain: temperature 101.3 F (38.5 C), white blood cell count 17K, creatinine 0.9 (baseline 0.7), BUN 25, albumin 1.7. Stool was positive for C. diff toxin. Despite 5 days of oral vancomycin, symptoms did not regress. Abdominal computed tomography (CT) imaging revealed pancolitis. Vancomycin was discontinued. Fidaxomicin was started. After 6 days of fidaxomicin, symptoms were unchanged. 25 grams of IVIG was given (347 mg/kg) as an adjunct to fidaxomicin. The next day, her stool count decreased from an average of 9 per day to 5. After once daily 25-gram IVIG treatment for 3 consecutive days, the patient had complete resolution of her abdominal pain and diarrhea.

DISCUSSION:
Inflammation and disease in CDI are mediated by toxins. Some studies documented poor immune response to C. diff toxins in patients with severe or refractory disease. IVIG addresses this issue, as it contains C. diff antitoxin antibodies that act as passive immunity to neutralize the toxins and help with disease resolution. This report is one of several documenting success with IVIG in severe CDI. However, IVIG use in C. diff is limited, partly due to its high cost but perhaps in larger part due to small-sample retrospective analyses deeming its benefits statistically insignificant. Larger prospective controlled studies investigating different doses, duration, and timing of IVIG therapy are necessary to fully clarify IVIG's role in CDI. Moreover, IVIG may prove to be cost-effective by preventing severe or recurrent disease. In cases of CDI refractory to standard antibiotic treatment, passive immunity with IVIG may be a reasonable adjunct to standard therapy.
1594 A Rare Case of Nivolumab-Induced Colitis
Authors: Kang Gurjeet , Venu Lakshminarasimhan , Quinn Michael , Orpiano Christopher L. , Staffetti Joseph , Ghanekar Dilip 
Published: October 2019

INTRODUCTION:
Over the past decade immune-checkpoint inhibitors have been playing an increasing role in cancer treatment. One of the targets of these therapies is the Programmed Death (PD-1) protein; a protein that prevents T cells from recognizing and attacking inflamed tissues and cancer cells. Our reports describes a case in which a patient treated with nivolumab, a PD-1 inhibitor, presented with endoscopic findings characteristic of ulcerative colitis (UC).

CASE DESCRIPTION/METHODS:
Our case involves a 69-year-old male with past medical history of metastatic melanoma who presented with complaints of diarrhea rectal bleeding. Patient was on nivolumab 3 mg/kg every 2 weeks which was started 5 months ago. He reported lower abdominal cramping, bright rectal bleeding and diarrhea ongoing for 4 days. Physical examination was significant for moderate tenderness to palpation in lower abdomen. Initial abnormal laboratory results including hemoglobin of 11.2 g/dL otherwise unremarkable comprehensive metabolic panel. On computed tomography (CT) of abdomen and pelvis he was noted to have marked colitis involving the ascending, transverse and descending colon. All the following stool testing was negative for clostridium difficile, stool cultures camplyobacter, salmonella, shigella, ova and parasite. Patient was noted to have pancolitis on colonoscopy and pathology showed acute and chronic inflammation with superficial ulceration. Nivolumab was stopped and he was started on IV methylprednisolone 80 mg TID. Patient had little improvement over the next three days and hemoglobin decreased to 8.0 g/dL. Therefore he was given a dose of infliximab 5 mg/kg. His symptoms improved and he was in complete clinical remission soon after discharge. Patient was continued on oral prednisone 100 mg daily and instructed to taper slowly over the coming months.

DISCUSSION:
The PD-1 pathway will continue to be manipulated in future cancer treatments. Inhibition of PD-1 pathway in mice has resulted in various autoimmune diseases. In a safety profile study with 576 patients on nivolumab dosing of 3 mg/kg the most common adverse effect was noted to be a fatigue in 25% of patients. The incidence of grade 3 or 4 colitis was noted to be present in 0.7% of patients or 4 in total. Although the incidence of severe colitis may be low, infectious etiology must be ruled out prior to initiating immunosuppressive therapy. Patients with corticosteroid resistant colitis should have prompt initiation of infliximab therapy.
1595 Kayexalate-Induced Colitis: A Rare Cause of Acute Abdomen!
Authors: Shahid Tamoor , Abbas Syed Hassan , Hertan Hilary 
Published: October 2019

INTRODUCTION:
Sodium polystyrene sulfonate (kayexalate) combined with sorbitol is a resin that exchanges sodium for potassium primarily in the colonic mucosa to treat hyperkalemia. It has been associated with ischemic colitis.

CASE DESCRIPTION/METHODS:
We present a case of a 78-year-old female with a medical history of renal disease requiring hemodialysis and heart failure, admitted with an ischemic right lower limb. She was started on an intravenous heparin drip as per vascular surgery recommendations. Overnight her potassium level was noted to be 5.9 mg/dL for which she was medically treated with dextrose solution, regular insulin along with three doses of oral 15 mg kayexalate. The next morning she complained of sudden onset abdominal pain. CT imaging showed pneumatosis along with asymmetric mural thickening of the cecum, concerning for cecal ischemia. The patient underwent emergent exploratory laparotomy which revealed ischemia of the cecum and ascending colon. A right hemicolectomy was done and the patient eventually made a complete recovery. Later, pathology revealed findings of ischemic colitis with detached purple refractile material in the colon consistent with kayexalate crystals.

DISCUSSION:
Colonic necrosis after the use of kayexalate is a rare and an under-recognized complication. Incidence of colonic necrosis is reported to be around 0.27% which increases to 1.8% in uremic patients. It often presents with nonspecific symptoms such as constipation, fecal impaction, obstruction, gastrointestinal bleeding, bezoars and rarely, acute abdomen as in our patient. Previously addition of sorbitol to kayexalate was thought to be the main culprit leading to colonic necrosis but cases have been reported in patients taking sorbitol free kayexalate. The exact mechanism of action remains unclear with a few possibilities such as a direct toxic effect, elevated prostaglandin levels and hyperreninemia in patients with renal insufficiency, leading to nonocclusive mesenteric ischemia, have been suggested. Endoscopically it presents as ulcerated lesions with a definitive diagnosis made after seeing kayexalate crystals on the histological exam. Patients without signs of peritonitis are usually managed medically with intravenous fluid resuscitation, use of supplemental oxygen, bowel rest and broad-spectrum antibiotics. Clinicians must be cautious in prescribing kayexalate to patients and keep kayexalate induced colitis in one of the differentials in patients presenting with signs and symptoms of colitis.
1599 Cronkhite Canada Syndrome: A Rare Cause of Dysgeusia and Protein Losing Enteropathy
Authors: Yalamanchili Silpa , Leroy Kyley , Heightchew Kimberly , Newman Gary 
Published: October 2019

INTRODUCTION:
Cronkhite Canada syndrome (CCS) is a rare, acquired polyposis syndrome associated with serious complications and a high mortality rate. Awareness regarding presenting symptoms, endoscopic findings, and pathologic features leads to early diagnosis and treatment, and improved survival.

CASE DESCRIPTION/METHODS:
68 yo female with a history of alopecia totalis presented with 6 months of non-bloody diarrhea, 30 lb weight loss, and dysgeusia. Physical examination revealed complete alopecia, pitting lower extremity edema, and thinning and splitting of the fingernails. Diagnostic workup yielded marked hypoalbuminemia (albumin 1.1 g/dL), positive SS-a antinuclear antibody (titer 1:160), and elevated serum total IgG level (1,750 mg/dL). CT was notable for a thickened stomach with edematous rugae, and focal segmental colitis involving the cecum and ascending colon. Push enteroscopy showed diffusely edematous mucosa in the gastric antrum and duodenum with denuded appearing vili throughout the small bowel. Colonoscopy revealed diffuse polyposis throughout the entire colon and terminal ileum, with edematous underlying colonic mucosa. Biopsies of affected areas showed diffuse cystic dilation, edema of the lamina propria, and presence of plasma cells, compatible with CCS. The patient was initiated on total parenteral nutrition, prednisone 40 mg daily, and Imuran 75 mg daily. In follow up, she reported complete resolution of dysgeusia, reduction in diarrheal symptoms, weight gain, and improved energy level. Serum albumin level improved to 2.92 g/dL.

DISCUSSION:
Cronkhite Canada syndrome is a sporadic, acquired polyposis syndrome characterized by diffuse gastrointestinal polyposis and ectodermal features. It carries a 5-year mortality rate of 55% despite therapy, due to a high rate of serious complications, including malabsorption, infection, heart failure, and GI bleeding. Patients are at high risk of gastric and colorectal malignancies (10.4% and 25%, respectively), necessitating annual screening examinations. A combination of nutritional support and immunosuppression with prednisone (tapered dosing) and imuran (2 mg/kg) helps in achieving clinical remission and avoiding relapse. Expedited diagnosis and application of therapy has led to improvement in patient survival and achievement of clinical response. Therefore, improved clinician awareness of disease manifestations, pathologic findings, and treatment regimen is necessary to modify the disease course for this syndrome.
1601 Cecal Granular Cell Tumour: An Uncommon Site of an Uncommon Tumour
Authors: Bandaru Praneeth , Ofosu Andrew , John Febin , Reddy Madhavi 
Published: October 2019

INTRODUCTION:
Granular Cell Tumors (GCTs) are tumors arising from Schwann cells of the nerve sheath. They occur at an incidence of about 0.03% and have a predilection for the skin, oral cavity, and breasts. Only 6-8% of all GCTs occur in the GI tract with the esophagus (65%) being the most common site, followed by the colorectum (25%). Less than 20 cases of cecal GCTs have been reported so far. Owing to its rarity, we report a case of an asymptomatic cecal GCT found incidentally during screening colonoscopy.

CASE DESCRIPTION/METHODS:
A 58-year-old male with no known past medical history presented to the Gastrointestinal (GI) clinic for screening colonoscopy. History was negative for alarm symptoms, including no family history of GI cancers. He had no prior Upper endoscopy or colonoscopy. Physical examination and labs were unremarkable. Colonoscopy revealed an 8mm yellowish, sessile, subepithelial nodule with normal overlying mucosa in the cecum (Figure 1). Biopsy showed clusters of cells with granular cytoplasm that was Periodic acid–Schiff (PAS) positive suggestive of GCT (Figure 2). Immunohistochemical staining was positive for S100, CD 68, calretinin thus confirming the diagnosis of GCT (Figure 3). The patient has since been scheduled for Endoscopic ultrasound (EUS) for further evaluation.

DISCUSSION:
Colorectal GCTs account for up to 25% of all GI GCTs, with most affecting the right sided colon (cecum and ascending colon). Mostly benign and solitary, but about 2% are known to have malignant potential with poor prognosis. More common in females and in African Americans between ages 40-60 years. Generally asymptomatic and found incidentally during a screening colonoscopy, however in a few cases, patients have presented with hematochezia, abdominal pain, and change in bowel habits. EUS is invaluable in differentiating GCTs from other subepithelial tumors, in determining the size, and depth of invasion. Definitive diagnosis is by histopathology and immunohistochemical staining. There is no general consensus on the management of colorectal GCTs. Conservative management is recommended for tumors < 1cm, asymptomatic, with no deep tissue invasion or malignancy. However, resection is warranted for symptomatic tumors, tumors >1 cm in size, deep tissue invasion or malignancy. Endoscopic removal is preferred over surgery for tumors without deep tissue infiltration or malignancy. Endoscopic and histologic surveillance every 1-2 years is recommended.
1605 Typhoid Fever: GI Bleed From an Ancient Disease
Authors: Curtis Stephen , Young Patrick 
Published: October 2019

INTRODUCTION:
Gastroenterologists periodically encounter ileocecal wall thickening in a patient with abdominal pain, fevers and gastrointestinal bleeding in an inpatient setting. A unifying diagnosis for a patient with these radiologic findings and symptoms could include inflammatory, infectious, or malignant etiologies. We present a case of a patient presenting in this way, who has found to have salmonella bacteremia as well as colonic and ileocecal valve ulcers on endoscopy.

CASE DESCRIPTION/METHODS:
A 51-year-old man with a past medical history notable for bladder cancer status-post BCG treatment presented with a three day history of crampy abdominal pain and fevers. He denied any diarrhea or vomiting. Exam was notable for a temperature of 102.7 and mild tenderness to palpation in lower abdomen. Admission labs were notable for normal leukocyte count and mildly elevated hepatocellular enzymes (AST 63, ALT 97). Due to his high fever, blood cultures were drawn. CT scan was notable for marked wall thickening at the ileocecal junction with enlarged regional lymph nodes. On the day after admission, he had a melenic stool and was scheduled for EGD and colonoscopy. EGD was unremarkable, but his colonoscopy was notable for two 3-5mm ulcers in the ascending colon as well as an ulcerated and inflamed ileocecal valve, which was unable to be intubated. Concern was for infectious or malignant etiology of these findings. Multiple blood cultures returned positive for Salmonella enterica with Vi antigen, shortly thereafter. He was treated with ceftriaxone and metronidazole for his bacteremia, and later transitioned to ciprofloxacin, with improvement in symptoms. Biopsies of the ulcers showed chronic active colitis. They were also notable for B and T cell clones which were concerning for lymphoma. To follow up on these concerns, he had repeat colonoscopy three weeks later which noted resolution of his ascending colon ulcerations and ileocecal valve inflammation. His terminal ileum was intubated and appeared normal. Biopsies of the ileocecal valve revealed benign colonic mucosa. After completion of antibiotic therapy, the patient denied any further symptoms.

DISCUSSION:
This case illustrates the importance of maintaining a broad differential in a patient with colonic inflammation on imaging and ulcerations noted on endoscopy. Also, this case highlights key features of typhoid colitis which can include GI hemorrhage with a predilection for right-sided colonic involvement.
1607 The Hidden Parasite
Authors: Rodriguez-Berrios Frances , Figueroa Ivonne , Martin-Ortiz Jose , Rosado Katia 
Published: October 2019

INTRODUCTION:
Parasite identification during routine colon cancer screening is unexpected and rather unusual. Schistosoma is a tropical parasite associated to freshwater snails; among which S. mansoni and S. japonicum species have been associated with intestinal tract infection. Although most patients are asymptomatic, identification is crucial to avoid possible complications like chronic intestinal schistosomiasis or hepatosplenic schistosomiasis.

CASE DESCRIPTION/METHODS:
A 57-year-old Puerto Rican Vietnam veteran with history of schizophrenia and chronic liver disease secondary to Hepatitis C underwent colonoscopy for average-risk colorectal cancer screening. During colonoscopy, a one-centimeter polyp at 15cm was completely removed by hot snare and six additional small sessile polyps in the rectum by cold forceps. Pathology was remarkable for a tubular adenoma, while one of the rectal polyps identified a non-necrotizing granuloma suggestive of schistosoma parasite. Patient had shown no GI symptoms or complaints and was treated with Praziquantel.

DISCUSSION:
Puerto Rico is an endemic area for schistosoma. Schistosomiasis is a chronic parasitic disease with significant cause of morbidity and mortality. Intestinal polyps and dysplasia can arise due to granulomatous inflammation surrounding eggs deposited in the bowel wall. Gastrointestinal manifestations may result in chronic abdominal pain, poor appetite, and diarrhea for which early identification is necessary for treatment even in the asymptomatic setting.
1610 Don't Let Your Past Determine Your Destiny
Authors: Pisipati Sailaja , Elliott Chistie , Crapko Matthew , Hsieh Ting Hui 
Published: October 2019

INTRODUCTION:
Synovial sarcoma (SS) is a rare mesenchymal soft tissue sarcoma usually involving extremities close to large joints. SS of the GIT is uncommon; SS of the colon is extremely rare. Recognition and management of SS of the GIT can be very challenging. Here we report a rare case of asymptomatic SS of the rectosigmoid diagnosed as a surprising finding of surveillance colonoscopy.

CASE DESCRIPTION/METHODS:
A 59-year-old asymptomatic lady with past medical history of diabetes mellitus, morbid obesity, colon polyps was referred for surveillance colonoscopy. Prior colonoscopy six years ago revealed two sigmoid colonic tubular adenomas. Examination was unremarkable except for a BMI of 44. Thorough examination of the musculoskeletal system did not reveal any abnormalities. Colonoscopy revealed a large, 5 cm pedunculated and superficially ulcerated round mass in the rectosigmoid colon, filling most of the lumen with the distal end of the lesion being ∼15 cm above the anal verge. Biopsy demonstrated spindle cells with marked nuclear pleomorphism, high mitotic index rate, positive SS18 (SYT) gene rearrangement testing on FISH. Immunohistochemistry (IHC) was positive for TLE1, OSCAR, MCK, AE1/AE3, CK7 with Ki-67 of 70% and negative for desmin, CD117, DOG1, p63, CK5, CK6, S100, SMA. Findings were consistent with SS. Staging CT and PET-CT did not demonstrate distant spread. Robotic laparoscopic anterior resection with wide surgical resection margins and lymphadenectomy revealed T1N1 LN 2/20 stage 3 monophasic synovial sarcoma, with negative margins, 20% tumor necrosis and high mitotic rate. The patient was started on adjuvant chemotherapy with 5 cycles of Adriamycin 75 mg/m2 and Olaratumab on day 1 and day 8 of a 21-day cycle. A repeat PET-CT and a flexible sigmoidoscopy, six months later, did not reveal any tumor recurrence.

DISCUSSION:
Increasing number of cases of GIT SS are being reported. The majority of GI SS cases involved esophagus and stomach with pain, obstruction and bleeding being the common presenting symptoms; SS of the large intestine is extremely rare. Diagnosis is established by molecular genetics and IHC. Standardized treatment-guidelines are currently lacking. It is of paramount importance to i) consider SS on the list of differentials of colonic neoplasms, ii) report these unusual cases to better understand the pathophysiology, treatment options and success rates. This would facilitate more targeted and effective treatments for SS of the colon.