bluuebunny/crossref_metadata_2025_split huggingface dataset:
1572 Strongyloides stercoralis AutoInfection
Authors: Melki Gabriel , Komal Fnu , Laham Linda , Karim Gres , Yuridullah Ruhin , Vora Aarohi , Zoldak Wioletta , Barham Shaker , Botros Youssef , Estifan Elias , Hajjar Bassam , Michael Patrick 
Published: October 2019

INTRODUCTION:
Strongyloides stercoralis is an intestinal roundworm that infect humans through contact with soil that is contaminated with free-living larvae. The larvae penetrate the skin and migrate through the body to the small intestine to lay their eggs. It is associated with immigrant populations from tropical regions such as Southeast Asia and the south pacific. Strongyloidiasis is often mild or asymptomatic in over 50%-60% of cases, but may present with cutaneous and gastrointestinal symptoms like abdominal pain, bloating and diarrhea. The rise in blood eosinophils count could be the only finding. Strongyloides is able to re-infect the host through the wall of gastrointestinal tract, a process described as autoinfection. This is why it may be detected decades after original exposure.

CASE DESCRIPTION/METHODS:
We encounter a 64-year old Hispanic male with PMH of Multiple Myeloma, who was admitted to our hospital due to fatigue and spiking fever. Patient was recently diagnosed with Multiple Myeloma and was on Bortezomib, Cyclophosphamide and Dexamethasone for the last 22 days. During the presentation, maculopapular rash was noted on his right inner thigh that later on got more diffused and affected the bilateral thigh and right forearm. Laboratory results shows Leukocyte 6.8 thousand/uL, hemoglobin 7.3 g/dL, platelet 35 thousand/uL, eosinophil 34 cells/uL, and plasma cell 2 cells. Patient had Tmax of 103 and empiric antibiotic was started. All blood cultures, urine cultures and chest X-ray was negative for any source. His liver enzymes and direct bilirubin trended up without any sign of cholecystitis on ultrasound and Cholescintigraphy scan. During the hospital course, the rash got more characteristic of reticulated purpuric patches. EBV, HSV, Varicella, Spotted fever, Typhus fever, ANA, IGG and hepatitis panel back negative. Due to reticular rash development, suspicion of Strongyloidiasis increased and IGG antibody came back positive. Patient started on Stromectol 15 mg for 2 doses and the rash resolved following the second dose of the medication.

DISCUSSION:
Strongyloides stercoralis is a challenging diagnosis in immunocompromised patients. It is important to screen for helminth diseases in patients with high blood eosinophils count, especially before starting chemotherapy.
1576 Use of Intravenous Immunoglobulin as a Treatment Adjunct for Refractory Clostridioides difficile Infection
Authors: Quinn Michael , Ghanekar Dilip , Venu Lakshminarasimhan , Kang Gurjeet , Orpiano Christopher L. , Staffetti Joseph 
Published: October 2019

INTRODUCTION:
Approximately 500,000 Clostridioides difficile infections (CDIs) occur annually in the USA. Recurrent CDI occurs in 20 to 30% patients with increasing rates of recurrence with each subsequent episode. Initial recurrences are treated with additional antibiotic regimens. Current treatment guidelines recommend fecal microbiota transplant (FMT) therapy after a 2nd recurrence treatment failure. Intravenous Immunoglobulin (IVIG) has been shown to be effective as a treatment adjunct in patients with CDI and hypogammaglobulinemia as well as in cases of severe and refractory CDI. Herein, we present a case of a patient with refractory CDI for two and a half years whose symptoms resolved after the addition of therapy with IVIG.

CASE DESCRIPTION/METHODS:
A 47 year old woman with refractory CDI for 2.5 years was admitted to our facility. She typically had 20 to 40 episodes of non-bloody diarrhea per day. Prior treatment courses included 4 fecal microbiota transplants, 13 oral vancomycin tapers, courses of metronidazole, 1 course of fidaxomicin, and colonic lavage with vancomycin installation, none of which provided relief for more than 1 week. Previously she had undergone EGD and colonoscopy with gastric, duodenal, colonic and terminal ileum biopsies which were unrevealing. Testing for celiac disease, TSH, ESR, CRP, gastrin level, Chromogranin A, vasoactive intestinal peptide 5-HIAA levels and stool osmolar gap were unremarkable. The patient had normal vital signs and had no major laboratory abnormalities. Total IgG was only slightly low at 667 mg/dL, normal range per hospital lab is 700-1600 mg/dL. Stool studies revealed persistent CDI. CT abdomen and pelvis w/o contrast showed no acute findings. She was started on Vancomycin 500 mg PO qid and diarrhea persisted. Colonoscopy with random biopsies revealed normal colonic mucosa and biopsies were negative. IVIG was added to enhance her immune response to refractory CDI. IVIG 20 g was administered daily for 2 days resulting in a dramatic decrease in diarrhea and the patient was discharged in good condition on hospital day 10.

DISCUSSION:
For our patient adjunctive treatment with IVIG led to resolution of infection and the avoidance of a total colectomy. We suggest consideration for incorporating IVIG therapy in difficult to manage CDI regardless of immunoglobulin status. A need remains for randomized control trials to better establish the optimal timing and dosing of IVIG in the treatment of CDI.
1578 A Rare Follicular Lymphoma of the Colon
Authors: Truscello David , Shah Maulik , Kolnik John 
Published: October 2019

INTRODUCTION:
Here we present a case of intestinal follicular lymphoma (IFL) originating in the colon. Pathology was confirmed from multiple institutions and the authors of this report could only find a few such instances in literature. We will go through the case, the diagnosis, endoscopic pictures, as well as patient outcome.

CASE DESCRIPTION/METHODS:
A 60 year old male presented for a routine screening colonoscopy. A single polyp, measuring between 10 and 20 mm, was found in the colon, 30 cm from entry site and removed with snare cautery polypectomy. Initial pathology was consistent with low grade B-Cell Lymphoma of possible marginal zone origin that was positive for BCL2, CD20, CD43, and Ki-67. A year later patient presented for follow up colonoscopy in which two additional polyps were found, one at the splenic flexure, one at 50 cm. Both of their pathology was CD10, CD20 positive and consistent with follicular lymphoma, grade 2. This finding was also confirmed by a reputable pathologist in a different health system. The recent polyps do bring into question as to whether the initial polyp was also follicular lymphoma. Patient underwent a subsequent bone marrow biopsy at the time that showed small atypical lymphoid aggregates.

DISCUSSION:
Intestinal follicular lymphomas (IFL) are a subtype of Non-Hodgkin's lymphoma that account from anywhere to 1-3.6% of all cases. Although there are not many cases present in literature, the authors did find a study indicating older caucasians were more prone to this diagnosis. While some patients present for evaluation of gastrointestinal complaints, our patient was asymptomatic when he presented for a routine colonoscopy. Multiple polyps were found that were consistent with lymphoma pathology. Most of these cases present on endoscopic evaluation as elevated lesions with no erosions or ulcerations. Consistent with primary follicular lymphomas, our patient's pathology also exhibited positive CD10 and CD20 immunohistochemical markers. Takata et al. reviewed prior cases of IFL and determined the small intestine is the most common site. However, multiple reports site that primary colon IFL only accounts for about 1-2% of IFL. Despite its rarity, the prognosis is fairly well with Chouhan et al. indicating a 5 year OS rate of 71.5%. The traditional FLIPI and FLIPI2 prognostic scales could not be used in this case as there have not been enough IFL cases to prove the effectiveness of this method. Our patient has since been stable in the 4 years following his latest polyp removal.
1579 Rare Finding of Incidental Ascending Colon Ganglioneuroma in the Setting of Hematochezia
Authors: Nehme Christian , Ghazaleh Sami , Ghanim Marcel , Khader Yasmin , Hasan Syed , Nawras Ali 
Published: October 2019

INTRODUCTION:
Ganglioneuromas are slowing growing tumors that are rarely found in the colon. Patients with colonic ganglioneuromas may present with nonspecific symptoms such as abdominal pain, bleeding, or change in bowel habits, but these patients are usually asymptomatic. We present a case of hematochezia where an ascending colon ganglioneuroma was incidentally found on diagnostic colonoscopy.

CASE DESCRIPTION/METHODS:
84 year old male with a past medical history of hypertension, chronic atrial fibrillation on rivaroxaban, COPD, and prostate cancer S/P radiation presented with hematochezia of two days duration. He had three loose bowel movements on the day of presentation with bright red blood and clots. This was associated with nausea and diarrhea, but patient denied abdominal pain, vomiting, hematemesis, melena, and weight loss. Last colonoscopy, around 7 years ago, was normal. On presentation, patient's vital signs were within normal limits. Physical exam revealed an irregularly irregular rhythm. Abdominal exam was within normal range. Rectal exam revealed dark red stools. No external hemorrhoids were seen. Laboratory findings revealed hemoglobin of 12.5 g/dl and an INR of 1.4 Rivaroxaban was stopped on presentation. Hemoglobin dropped to 11 g/dl then became stable. Colonoscopy was performed five days later. It showed a 3 mm polyp in the ascending colon, a 4 mm polyp in the descending colon, and diverticulosis in the descending colon. The 3 mm polyp in the ascending colon was removed with a cold biopsy forceps. Histological examination of the specimen showed ganglioneuroma.

DISCUSSION:
Ganglioneuromas are hamartomatous tumors that are rarely seen in the gastrointestinal tract, and are usually found incidentally. There are three different subtypes of ganglioneuromas: polypoid ganglioneuroma, ganglioneuromatous polyposis, and diffuse ganglioneuromatosis. The most common type is polypoid ganglioneuroma which is usually a small single polyp arising from the mucosa and submucosa. Definitive diagnosis of ganglioneuroma can only be done through pathological and histological examination. Treatment depends on their size, location, and subtype in addition to the patient's clinical history. Polypoid ganglioneuroma, which is present in this patient, is a benign lesion, so endoscopic resection using a biopsy forceps or a snare is usually curative. It may also be useful to perform a follow up colonoscopy to ensure complete excision of the lesion.
1584 A Rare Case of Follicular Lymphoma of Sigmoid Colon
Authors: Mohy-ud-din Nabeeha , Umar Shifa , Kulkarni Abhijit , Morrissey Suzanne 
Published: October 2019

INTRODUCTION:
Follicular lymphoma is defined as a neoplasm of follicle B cells and is characterized immunohistochemically by a positive reaction to B-cell markers and Bcl-2. Follicular lymphomas of the colon are very rare. Within GI Lymphomas, colorectal lymphomas are very uncommon and account for only 3% of GI lymphomas and 0.3% of large intestinal malignancies. We describe an unusual presentation of extra-nodal follicular lymphoma within the sigmoid colon.

CASE DESCRIPTION/METHODS:
A 59-year-old Caucasian female with history of hypertension was referred by her primary care physician for an average risk screening colonoscopy. Prior to referral for screening colonoscopy, the patient was being screened for colon cancer with annual occult stool testing which had been negative. She underwent a colonoscopy which showed a sessile polyp in the hepatic flexure and two polypoid lesions in the sigmoid colon (Figure 1). The patient was referred for endoscopic mucosal resection of the polyps. A snare mucosal resection was performed for the hepatic flexure polyp (12 mm in size). The 2 sessile polyps in the sigmoid colon (8-12 mm in size) were also resected with a hot snare. Pathology from the sigmoid colon polyp was consistent with Grade IIIA Follicular Lymphoma and immunohistochemistry was positive for CD20, CD10, BCL6 and BCL2 (Figure 2). The polyp in the hepatic flexure was noted to be a benign sessile serrated polyp. Patient was referred to Oncology for further management. A bone marrow biopsy and PET/CT did not show any evidence of disease involvement elsewhere.

DISCUSSION:
Primary NHLs of the GI tract are rare, accounting for only 1 to 4 percent of malignancies arising in the stomach, small intestine, or colon. Colonoscopy with biopsy is the principal diagnostic modality. Colonoscopic findings of follicular lymphomas include mucosal ulcerations, diffuse mucosal nodularity or polypoid mass like lesions. However, due to its rarity, an optimal diagnostic work up and treatment plan has not been well established. Making a correct diagnosis of the disease based on findings of biopsied samples can be challenging and multiple biopsies or endoscopic mucosal resection may be required in addition to appropriate consultation with pathologists.
1587 Ogilvie Syndrome Associated With Chronic Baclofen Use
Authors: Akhtar Nabeel , Kim Alex , Bhaskar Benny , Coates Matthew 
Published: October 2019

INTRODUCTION:
Ogilvie syndrome is common in hospitalized patients and can be contributed by medications such as opioids and anti-cholinergics. We present a case of a 70 year-old male with Ogilvie syndrome associated with chronic baclofen use.

CASE DESCRIPTION/METHODS:
A 70 year-old male with chronic obstructive pulmonary disease (COPD), peripheral neuropathy and spastic hemiplegia treated with baclofen for four years presented to the emergency room with a four-day history of progressively worsening abdominal distension, constipation, poor oral intake, and reduced urine output. He was hospitalized for a COPD exacerbation managed with steroids and breathing treatments. Physical examination demonstrated a significantly distended abdomen without bowel sounds and mild tenderness to palpation without peritoneal signs. Blood tests did not note any electrolyte disturbances. CT imaging without contrast showed gaseous distension of the colon with scattered stool and compression deformities of the T8, T9, T11, L1 and L5 vertebrae. Concerning for an ileus or colonic obstruction, patient was made nil per os (NPO) and had nasogastric and rectal tubes inserted. Despite an aggressive bowel regimen including polyethylene glycol, senna, and rectal enemas, patient's gastrointestinal symptoms did not resolve. Repeat exams demonstrated progressive distension and tenderness to palpation. Abdominal x-ray (AXR) showed persistently dilated large bowel loops and a possible transition point in the distal sigmoid colon. He then underwent a flexible sigmoidoscopy for further evaluation and stool disimpaction; no physical obstruction was encountered, but the colonoscope did not pass beyond the sigmoid colon due to a considerable solid stool burden. He was continued on a bowel regimen with trials of lubiprostone and neostigmine; however, these interventions only led to modest liquid stool output. Finally, baclofen was discontinued, and in the next day, the patient passed solid bowel movements with progressive improvement in his exams. Post-discharge, repeat AXR showed decreased gaseous distension of the transverse and descending colon. Patient was advised to discontinue baclofen.

DISCUSSION:
Medications can lead to colonic pseudo-obstruction - Ogilvie syndrome - particularly in people with severe comorbidities or acute illnesses. Baclofen has previously been associated with Ogilvie syndrome. When prescribing baclofen, providers must warn patients to monitor stool output and strongly consider administering a bowel regimen.
1589 Unusual Presentation of Adenocarcinoma Ex Goblet Cell Carcinoid
Authors: Rojas Patricia Guzman , Gonzaga Ernesto Robalino , Henriquez Richard , Parikh Jignesh 
Published: October 2019

INTRODUCTION:
Ex Goblet cell carcinoid (eGCC) is a type of goblet cell carcinoid tumor, characterized by both endocrine and exocrine features, that has carcinomatous growth patterns. The classical presentation is compatible with symptoms of acute appendicitis. However, other signs and symptoms such as bowel obstruction, GI bleed and less commonly mesenteric adenitis or iron deficiency have been reported.

CASE DESCRIPTION/METHODS:
A 72 year old man with a recent hospitalization due to symptomatic anemia, presented to the ED complaining of diffuse abdominal pain for the past 3 weeks. He also reported nausea and emesis for 12 hours. At the previous admission, a CTE (Figure 1) showed thickening of the TI and an EGD was unremarkable. A colonoscopy was recommended, but it was scheduled for completion as an outpatient. At this admission, his hemoglobin was within normal limits, however his abdominal pain and nausea were persistent despite medical treatment. A repeated CT abdomen showed the same TI thickening with an associated new SBO (Figure 2). General surgery was then consulted and the patient underwent an exploratory laparotomy. Intraoperative findings showed possible carcinomatosis, and thence an ileocolectomy and ileocolostomy were performed. Pathology findings were compatible with adenocarcinoma ex goblet cell carcinoid of the appendix (Figure 3), and for this reason, he was referred to oncology for further management.

DISCUSSION:
GCC can be classified into 3 groups according to the presence of adenocarcinoma component and its degree of differentiation which directly correlates with its prognosis. Group A exhibits only pure goblet cell carcinoid cells; group B shows goblet cells with signet ring cells, and group C presents with goblet cell cells with a component of adenocarcinoma. eGCC corresponds with group C, which is the type presented in our case. Most patients have metastatic disease at the time of diagnosis, estimated in 60% to 91% of the cases. Due to the rarity of this type of tumor, currently there are no guidelines for treatment. However, the main approach is based on surgical resection of the appendix versus right hemicolectomy if the tumor is not confined to the submucosa. In terms of adjuvant treatment, FOLFOX/FOLFIRI are currently being used in most institutions. We present this patient due to its rarity and unusual presentation. Furthermore, we would like to incentivize future researches that can focus on implementing treatment guidelines for this tumor, due to its associated poor prognosis.
1591 Melanosis Coli Aids Endoscopic Differentiation of Polyp Histology in Cowden Syndrome
Authors: Farah Filsan , Pearlman Rachel , Arnold Christina , Stanich Peter P. 
Published: October 2019

INTRODUCTION:
Cowden syndrome is a rare disorder related to germline mutations in the PTEN gene. Although considered a hamartomatous polyposis syndrome, emerging evidence has shown colorectal polyposis with mixed histologic types (including adenomas) to be most common. This can make endoscopic surveillance difficult. Melanosis coli is characterized by dark pigmentation of the colon. Adenomatous and hyperplastic polyps remain pale in this setting and are easily visualized, but there are no published reports on the appearance of hamartomatous polyps.

CASE DESCRIPTION/METHODS:
A 55-year-old man with intellectual disability was referred to our institution for consideration of colectomy due to colorectal polyposis. He was then referred to GI Genetics clinic for further evaluation prior to surgery. His history included innumerable colon polyps on previous colonoscopies. Available pathology included multiple colon polyp types including tubulovillous and tubular adenoma, serrated adenoma, hyperplastic and inflammatory polyps. His family history included twin brother with brain tumor, mother with breast cancer and stomach cancer and father with brain cancer. Examination showed macrocephaly with head circumference of 62 cm. Cowden syndrome was suspected and genetic testing was performed. This showed a pathogenic mutation in the PTEN gene and confirmed the diagnosis. Surveillance colonoscopy was performed. This showed diffuse melanosis and polyposis of the colon. There were 4 colon polyps that were pale and visually consistent with adenomas. These were resected and returned as 3 tubular adenomas and a serrated adenoma with minimally apparent melanosis on histologic assessment. There were multiple diminutive polyps throughout the colon that were dark and appeared visually consistent with hamartomas. Many of these were sampled and were consistent with hamartomatous polyps with prominent melanosis histologically. Given the ability to endoscopically differentiate between neoplastic and benign polyp histologies, ongoing surveillance colonoscopy was recommended and colectomy was avoided.

DISCUSSION:
Polyposis with mixed polyp histology is common in Cowden syndrome and complicates endoscopic surveillance. In our patient with melanosis coli, hamartomatous polyps remained dark and matched the surrounding mucosa while adenomas and serrated adenomas were pale and easily distinguishable. This is the first report of the appearance of hamartomas in the setting of melanosis to our knowledge.
1596 Adult Colocolic Intussusception: A Case Series
Authors: Shahid Tamoor , Hertan Hilary 
Published: October 2019

INTRODUCTION:
Intussusception of the bowel is defined as the telescoping of a proximal segment of the gastrointestinal tract within the lumen of the adjacent segment and is found frequently in children. It is less common in adults. Most of the intussusceptions in adults are caused by a definite underlying disorder such as neoplasm.

CASE DESCRIPTION/METHODS:
•A 26-year-old healthy male presented with acute left abdominal pain. Examination showed minimal tenderness in the left lower quadrant with no palpable mass. An abdominal CT scan showed intussusception along with regional pericolic lymph nodes. Colonoscopy was performed which showed a 5 cm ulcerated, partially obstructing mass in the descending colon. The patient underwent laparoscopic left hemicolectomy later and biopsy results showed moderately differentiated invasive adenocarcinoma, mucinous type, with no lymphovascular invasion. •A 44-years-old healthy male presented with severe abdominal pain and distention. Examination revealed severe abdominal tenderness and distention with diminished bowel sounds. Abdominal imaging revealed right-sided colocolic intussusception with possible underlying mass, dilated small bowel loops consistent with small bowel obstruction and innumerable hepatic metastases. The patient went for emergent right hemicolectomy. Pathology showed invasive adenocarcinoma of the cecum. The patient is planned for chemotherapy by oncology. •An 84-years-old female with no history of colonoscopy came for evaluation of right side abdominal pain. She had abdominal imaging which showed colocolic intussusception noted at the hepatic flexure with associated wall thickening, suggestive of underlying colonic mass. GI and Surgery evaluated the patient for endoscopic diagnostic workup and possible surgical intervention based on that but the family refused and opted for comfort care.

DISCUSSION:
Adult intussusception occurs relatively rarely; accounting for 5% of all cases of intussusceptions. A specific lead point is identified in more than 90% of cases while 10% of cases are idiopathic. Malignant lesions account for up to 30% of cases in the small intestine and 66% of the cases in the large intestine. An abdominal CT scan is the diagnostic modality of choice in these patients. It may also help in defining the location, the nature of the mass and it may help to stage the patient with suspected malignancy causing the intussusception. Intussusception associated with malignancy should be managed by multispecialty collaboration.