bluuebunny/crossref_metadata_2025_split huggingface dataset:
1631 A Rare Case of Myxedema Ascites and Ischemic Colitis
Authors: Riaz Sana , Gowtham Sriharsha , Shafi Chilsia , Masood Umair , Kudaravalli Pujitha , Sharma Anuj , Mirchia Kanish , Ozden Nuri 
Published: October 2019

INTRODUCTION:
Myxedema is a severe form of hypothyroidism with various signs and symptoms. We present a rare case of myxedema ascites complicated with ischemic colitis (IC).

CASE DESCRIPTION/METHODS:
A 71-year-old female with a history of coronary artery disease and congestive heart failure (Ejective fraction 40%) presented with abdominal distention. Pertinent vitals included blood pressure of 100/54 mmHg and heart rate 38 beats/min. Pertinent labs included hematocrit of 28.2 %, albumin 3.1 g/dL, transaminases mildly elevated, alkaline phosphatase (ALP) 382 IU/L, thyroid stimulating hormone (TSH) 141 IU/mL, free triiodothyronine (T3) 1.26 pg/ml, total T3 45.30 ng/dL. Rest of the electrolytes, blood counts, including coagulation parameters, were normal. Electrocardiogram showed sinus bradycardia. She was started on levothyroxine for severe hypothyroidism. Abdominal ultrasound showed a large volume of ascites and normal liver contour. Paracentesis showed total nucleated cells of 2242, total protein 3.6 g/dL, lactate dehydrogenase 229, albumin 1.8 g/dL, serum ascites albumin gradient (SAAG) < 1.1, and glucose 86 mg/dL. Ascitic fluid cultures were negative. Hence, the patient was diagnosed with neutrocytic ascites and treated with empiric antibiotics. Ascitic fluid was negative for malignancy and tuberculosis. She was managed with diuretics (furosemide and spironolactone) and therapeutic paracentesis. She later developed bloody diarrhea, and flexible sigmoidoscopy showed mild to moderate IC of the rectosigmoid colon. She was treated conservatively. Her transaminases normalized, but ALP remained elevated. She was discharged after a two-week hospital stay and six weeks follow up showed significant improvement in ascites and TSH of 10 IU/mL.

DISCUSSION:
Myxedema ascites is seen in only 4% of the patients with uncontrolled hypothyroidism. There are no case reports on IC in the setting of myxedema ascites thus far. It is a rare complication of myxedema megacolon; however, our patient had no signs of megacolon on repeated imaging. Therefore, our case is unique as it highlights a rare (ascites) and uncommon (IC) complication of severe hypothyroidism. Ascites with SAAG < 1.1 should prompt physicians to consider hypothyroidism in the differential diagnosis for ascites especially when total ascitic fluid protein is > 2.5 g/dL and other causes such as portal hypertension, malignancy, and infections are ruled out. It is easy to treat, can lead to complete resolution of ascites and decrease morbidity.
1637 Bacterial Enteritis as a Red Herring in Workup for Fever of Unknown Origin
Authors: Wahid Nabeel , Buffie Charlie , Wan David 
Published: October 2019

INTRODUCTION:
The evaluation for fever of unknown origin (FUO) can often be misled by anchoring on incidental findings. Here, we describe the case of a patient with a FUO and new-onset diarrhea incidentally found to have a bacterial colitis.

CASE DESCRIPTION/METHODS:
A 72-year-old female was seen by the Gastroenterology consult service for new-onset of diarrhea in the context of 2-3 weeks of fevers, leukocytosis, and malaise. CT revealed colonic wall thickening suggestive of colitis and GI PCR revealed enteroaggregative Escherichia coli (EAEC). Inflammatory markers revealed ESR >130, and CRP 37.7. The patient had persistent fevers and leukocytosis despite antibiotics. PET scan showed no evidence of infection or malignancy. A bilateral temporal artery biopsy was obtained, which showed temporal arteritis (GCA). Fevers resolved with steroids.

DISCUSSION:
Uncomplicated gastrointestinal infections without abscesses typically do not cause ESR elevations >100. Our patient’s markedly elevated inflammatory markers suggested that EAEC colitis was an unlikely explanation for her diarrhea and fever. Though similar data is lacking in adults, a cohort of children with E. coli enteritis had ESR ranging from 2-48 and CRP from 0.02-10.25 (Kim, Y et al., Infect Chomother, 17 Dec 2017, 275-281). Common etiologies of ESR elevations >100 include infectious (mostly pneumonia, cellulitis, bacteremia, abscesses, or osteomyelitis), autoimmune, and malignancy (Daniels, LM et al., Mayo Clinic Proc., Nov 2017, 1636-1643). Thus, EAEC colitis was a red herring in our workup for our patient with a FUO. A widely used algorithm for FUO (Figure 1) would have suggested that no further workup was necessary for our patient after her CT revealed colitis in the setting of diarrhea and EAEC. We conclude that systemic inflammatory markers may be helpful in patients with suspicion for bacterial enteritis as an etiology of prolonged fevers. In our case, the profoundly elevated systemic inflammatory markers lead us to continue down the algorithm for FUO, leading to our biopsy proven diagnosis of GCA. GCA is most commonly seen in patients >50 years old and should be considered in patients with FUO within this demographic even when symptoms are not present.
1641 Ganglioneuroma Found on Routine Screening Colonoscopy
Authors: Engelberg Rachel , Wan David 
Published: October 2019

INTRODUCTION:
Ganglioneuromas are benign tumors of the sympathetic nervous system that carry a great prognosis with almost no change in clinical mortality. They are often asymptomatic, though can present with symptoms such as abdominal pain or constipation if large enough. These tumors are exceedingly rare and are curative with resection. Currently, there are no clear guidelines in the literature on appropriate surveillance for such patients. Here we present a case of a ganglioneuroma found in an asymptomatic patient on routine screening colonoscopy.

CASE DESCRIPTION/METHODS:
A 78-year-old woman with a past medical history significant for atrial fibrillation and hypertension was referred for routine screening colonoscopy for colorectal cancer. The patient was asymptomatic and had no diarrhea, constipation, hematochezia, or melena. She had no family history of gastrointestinal diseases nor record of any previous colonoscopy. Upon colonoscopy, four polyps were visualized on colonoscopy within the hepatic flexure, splenic flexure, descending colon and sigmoid colon, as well as diverticulosis in the sigmoid and ascending colon. Polyps were fully resected and retrieved with cold snare. The pathology returned with normal colonic mucosa within the splenic flexure, tubular adenomas in the hepatic flexure and descending colon, and a ganglioneuroma in the sigmoid colon. The patient was recommended for repeat surveillance colonoscopy in three years based on the adenoma.

DISCUSSION:
Ganglioneuromas are an exceedingly rare benign neoplasm of the colon, often with no clinical symptoms as seen in our patient. Therefore, these tumors are primarily diagnosed on routine screening colonoscopy. Given the rarity of this clinical entity, there are no current guidelines available for how to appropriately follow these patients. Such tumors have an excellent clinical prognosis and tend not to recur, therefore it is generally accepted that these patients require no surveillance screening. Given that our patient had concomitant tubular adenomas, she was recommended for follow up colonoscopy in three years. Resection of ganglioneuromas is curative and thus the mainstay of treatment. Our patient is unique as identifying these tumors is rare and infrequently reported in the literature.
1642 Pelvic Congestion Syndrome: An Unusual Manifestation of Sigmoid Pneumatosis Cystoides Intestinalis
Authors: Hussain We'am , Akram Salma 
Published: October 2019

INTRODUCTION:
Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by gas-filled cysts in the intestinal subserosa and submucosa. We present a rare case of primary PCI affecting sigmoid colon complicated by pelvic congestion syndrome (PCS).

CASE DESCRIPTION/METHODS:
A 34-year-old morbidly obese female presented with diffuse lower abdominal pain and intermittent foamy diarrhea without blood or mucus for the past 5 months. CT abdomen showed small bubbles of gas in the peritoneum in the left upper quadrant and large amount of cystic pneumatosis in a loop of sigmoid colon. Lab work was unremarkable. She was given one week course of antibiotics. A repeat CT scan 5 months later showed interval resolution of free intraperitoneal air but pneumatosis bubbles had enlarged in size. A colonoscopy was performed which showed large cystic-appearing air-filled bullae in sigmoid colon causing some luminal narrowing and the scope could not be safely advanced beyond mid-transverse colon. Patient underwent laparoscopic sigmoid colectomy and intraoperatively noted to have dilated and tortuous bilateral gonadal veins. Surgical pathology showed multiple clear fluid-filled cysts throughout the length of the specimen with viable and unremarkable proximal and distal resection margins. Patient recovered well from surgery and was discharged with no further complaints.

DISCUSSION:
PCI is an unusual condition caused by a myriad of underlying pathophysiological processes that range from benign to life-threatening conditions. Primary PCI is rare (15%), while underlying conditions for secondary PCI can be divided into several groups; traumatic, mechanical, inflammatory, autoimmune, infectious, pulmonary and drug (steroids and chemotherapeutic agents) induced. Conservative management is preferable except in cases of clinical deterioration. This case is unique because even after the resolution of free intraperitoneal air the patient continued to have lower abdominal and pelvic pain with worsening of pneumatosis on repeat CT scan several months later. It is possible that sigmoid anatomic changes due to pneumatosis resulted in chronic intermittent venous obstruction of pelvic veins leading to gonadal veins dilation and tortuosity and hence secondary PCS which resulted in ongoing lower abdominal pain. This case highlights the fact that persistent PCI, with ongoing abdominal symptoms even in the absence of any obvious etiology warrants laparoscopic exploration to rule out any underlying disease process.
1643 Colonic Malakoplakia: An Exquisitely Rare Cause of Lower GI Bleeding
Authors: Jessamy Kegan , Rawlins Sekou , Sheth Yesha , Zhang Shengle 
Published: October 2019

INTRODUCTION:
Malakoplakia is a rare chronic granulomatous disease that may affect many organs. The gastrointestinal tract is the second most common site of involvement (after the urinary tract). The most common sites of colonic involvement are the rectum, sigmoid, and right colon, in descending order of frequency. The pathogenesis of malakoplakia is unknown. The treatment of malakoplakia ranges from antibiotic therapy to surgical resection. Here we describe a case of a 33-year-old man who presented with hematochezia and was noted to have malakoplakia on rectal mass biopsy during colonoscopy.

CASE DESCRIPTION/METHODS:
A 33-year-old man presented to our clinic due recurrent episodes of painless hematochezia in the setting of warfarin for recent lower extremity deep venous thrombosis. He is a resident of a nursing home due to a complex neurosurgical history which includes resection of a right temporal glioblastoma multiforme tumor followed by chemo and radiation therapy. He also had subsequent craniotomy and ventriculo-peritoneal shunt placement and used oral dexamethasone for recurrent episodes of cerebral edema related to residual brain tumor. Despite stopping warfarin he continued to have rectal bleeding. Colonoscopy showed a frond-like/villous, fungating and polypoid non-obstructing circumferential mass in the rectum. Biopsies showed malakoplakia. After multidisciplinary discussions, a decision was made to continue dexamethasone to minimize cerebral edema and bowel resection was declined by patient’s parents. We opted to use a prolonged course of Ciprofloxacin, however, the patient developed severe urosepsis and unfortunately died.

DISCUSSION:
First reported by Michaelis and Gutmann in 1902, malakoplakia is derived from the Greek “malakos” (soft) and “plakos” (plaque) and reflects its usual endoscopic appearance as a friable, yellow mucosal lesion. Coliform bacteria in macrophage cytoplasm (von Hansemann histiocytes), and laminated intracytoplasmic inclusion bodies (Michaelis-Gutmann bodies) are characteristic. A decrease in macrophage cyclic GMP activity with resultant impaired bactericidal activity is hypothesized to be the cause of malakoplakia. Macrophage abnormalities and clinical symptoms resolve after discontinuation of glucocorticoids. Antibiotics such as ciprofloxacin have been successful treatments in few case reports. Unfortunately our patient did not have the opportunity to utilize any of these antibiotics prior to his passing.
1648 A Rare Case of Primary Colonic Lymphoma With Paraneoplastic Hypercalcemia
Authors: Augustine Thomas , Perisetti Abhilash , Khan Salman Ali , Garg Shashank , Inamdar Sumant , Tharian Benjamin 
Published: October 2019

INTRODUCTION:
Primary colonic lymphoma (PCL) is a rare malignancy accounting for 1% of all gastrointestinal (GI) lymphomas and 0.1-0.5% of all colorectal malignancies. 15% of Non-Hodgkin Lymphoma develop hypercalcemia at some point during their clinical course but rarely symptomatic at the time of diagnosis. We report a rare case of symptomatic hypercalcemia from an ascending colon mass which was diagnosed as Diffuse large B cell lymphoma (DLBCL).

CASE DESCRIPTION/METHODS:
A 63-year-old male with history of type II Diabetes mellitus and hypertension presented with worsening confusion over a week. He also endorsed weight loss of 35 lbs in a month, intermittent right sided abdominal pain, constipation and dark colored stools on multiple occasions. He had a normal colonoscopy 5 years ago. Physical examination showed stable vital signs and hard palpable mass with ill-defined borders in the right flank. Labs were significant for Hemoglobin 8.2 g/dL, Creatinine 3.7 mg/dL, Calcium 13.1 mg/dL and ionized calcium of 7 mg/dL. Liver function tests and serum ammonia were normal. Computed tomography (CT) scan of abdomen showed 16 × 15 × 15 cm exophytic mass with central necrosis arising from the distal ascending colon (Figure 1). Colonoscopy (Figure 2) mediated biopsy was consistent with DLBCL. Bone marrow biopsy and PET- CT scan were negative for extracolonic lymphoma. A diagnosis of PCL was made based on Dawson’s criteria. He underwent a right hemicolectomy. Grossly the mass measured 20 × 18 × 14 cm with a necrotic center eroding the colonic mucosa (Figure 3). He was started on combination chemotherapy (R-CHOP regimen: Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, Prednisolone) and Lenalidomide was added as his DLBCL was ABC (Activated B cell) type. Work up for hypercalcemia showed suppressed PTH levels, normal PTHrP, normal 25 OH Vitamin D and elevated calcitriol, consistent with increased production of calcitriol as the cause.

DISCUSSION:
Cecum is the most common site for PCL (60 – 75%), followed by rectosigmoid region (8.5 – 35%). This patient had mass in distal ascending colon which is an unusual location. Immunosuppression and Inflammatory bowel disease are the known risk factors for PCL, but often none could be identified. Hypercalcemia in NHL is mostly due to extrarenal production of 1,25-dihydroxyvitamin D facilitated by the 1α-hydroxylase enzymes in the macrophages that surrounds the malignant lymphocytes. In most series, surgery followed by multiagent chemotherapy (R-CHOP) has led to improved outcome.
1652 Missing Intrauterine Device Rediscovered in a Sigmoid Colon Polyp Nearly a Decade After Insertion
Authors: Kobeszko Matthew , Kuruvilla Aneesh , Gordon Melanie , Aubeid Firas , Almouradi Tarek 
Published: October 2019

INTRODUCTION:
Intrauterine devices (IUD) are a popular form of contraception with an overall low risk of complications. We report a patient with an IUD placed 8 years ago with the rare incidence of asymptomatic migration into a sigmoid polyp discovered with colonic rectal ultrasound requiring surgical removal.

CASE DESCRIPTION/METHODS:
A 50-year-old gravida 5 para 5 female presented with right lower quadrant pain for 1 week. Pain described as intermittent and radiating to her right flank. Last menstrual period was 3 weeks prior to presentation. She denied any fever, nausea, vomiting, vaginal bleeding, hematochezia or melena. History included IUD placement 8 years ago, nevertheless became pregnant. At that time, patient was informed her IUD had fallen out and proceeded with tubal ligation postpartum. Labs were within normal limits with a negative urine analysis and pregnancy test. Computed tomography of the abdomen/pelvis demonstrated translocation of IUD to the sigmoid colon wall. Gastroenterology performed a colonoscopy with rectal ultrasound that confirmed a metallic object in a sigmoid colonic polypoid lesion. Subsequently, general surgery performed a robotic assisted laparoscopic sigmoid colon resection. Her abdominal pain subsidized and patient was discharged home in stable condition.

DISCUSSION:
Uterine perforation and migration into abdominopelvic structures is a known, but rare complication to IUD usage, at a rate of less than 1 per 1000 applications. Perforation generally occurs during IUD insertion and risk factors include anatomically flexed uterus, clinician inexperience, and placement postpartum when the uterus is relatively thin walled. Many cases of perforation are asymptomatic and not discovered until years later. However, relatively few cases in the literature describe perforation with migration into the sigmoid colon. Reported cases describe IUDs placed postpartum becoming embedded in the uterus, with subsequent pregnancy, and uterine contractions forcing the IUD through the uterine wall and into the pelvic cavity. Treatment typically involves endoscopic foreign body retrieval. However, cases at high risk for bleeding or endoscopic limitations require surgical laparoscopy for safe removal. We highlight the utility of colonic ultrasound as safe and minimally invasive procedure to establish the diagnosis. While typically asymptomatic, migrated IUDs are a serious complication that can be diagnosed through computed tomography or colonic ultrasound requiring prompt foreign body removal.
1655 Removal of a 6CM Appendiceal Orifice Polyp With Snare Cautery Polypectomy
Authors: Castano Juan , Rapoport Grigoriy , Rivera Arturo Suplee , Nathani Muhammed , Zamir Asif 
Published: October 2019

INTRODUCTION:
Appendiceal orifice (AO) polyps are uncommon. They are usually removed surgically due to technical difficulties and high risk of perforation with endoscopic intervention. In the following case we present a patient with a 6 cm AO polyp removed successfully with snare cautery technique during colonoscopy.

CASE DESCRIPTION/METHODS:
A 66-year-old man presented to our clinic for colorectal cancer screening. During colonoscopy, careful inspection of the AO revealed a subtle bulge. A submucosal injection of the AO using Eleview revealed a 6cm cauliflower-like lesion. The AO polyp was then removed with snare cautery polypectomy technique without any complications. The edges were approximated with endoscopic mechanical clips. Biopsy results showed tubular adenoma without dysplasia.

DISCUSSION:
The majority of AO polyps are removed surgically due to potential complications, especially perforation. Currently, there are no guidelines that discuss management of these polyps due to lack of available data. A retrospective study involving 131 patients from multiple tertiary centers showed that polyps more than 20 mm in size undergoing endoscopic resection had significantly higher rates of perforation. Another retrospective study of 691 patients found that AO polyps greater than 5 mm in size were more likely to require surgery. Additionally, it has been reported that AO polyps encompassing more than 75% circumference have low resection rates. To our knowledge, this case is one of the largest endoscopic removal of an AO polyp encompassing the majority of the AO circumference without complications. Although traditionally AO polyps are removed surgically, our case suggests an alternative, less invasive and effective method of removing these difficult polyps. In order to validate our claim, documentation of more cases would be required.
1656 Gastrointestinal Whipple’s Disease Complicated With Meningoencephalitis, Ataxia, and Bilateral Uveitis
Authors: Castano Juan , Rapoport Grigoriy , Rivas Cynthia , Rivera Arturo Suplee , Zamir Asif 
Published: October 2019

INTRODUCTION:
Whipple’s disease (WD) is a rare systemic infection caused by the gram-positive bacterium Tropheryma whipplei. It classically presents as a malabsorption syndrome, but can involve other organs. Incidence is estimated to be 1–3 persons for every one million people. We present a patient with WD complicated by meningoencephalitis, ataxia, and bilateral uveitis.

CASE DESCRIPTION/METHODS:
A 68-year-old man presented to clinic for nonbloody diarrhea, unintentional weight loss, and joint pains. EGD with duodenal biopsy revealed intracellular periodic-acid Schiff positive bacteria compatible with WD. He was began on a one year course of oral Bactrim twice daily. Eight years later, he presented with altered mental status and ataxia to the hospital. Head imaging was unremarkable. Polymerase chain reaction (PCR) for Tropheryma whipplei was positive in both cerebral spinal fluid (CSF) and vitreous fluid. Repeat EGD with duodenal biopsy was negative for WD. He received a three-week course of IV Meropenem and was switched to IV Ceftriaxone on discharge with plans to receive 2 weeks as outpatient. Afterwards, he once again received a one year course of oral Bactrim. On follow up, his diarrhea had resolved and mentation had improved.

DISCUSSION:
WD presents a diagnostic challenge due to nonspecific symptoms similar to those in our patient. Histology of duodenal mucosa is the most reliable diagnostic method, however, molecular–biological methods are often required. In one cohort, 99.4% of patients had positive duodenal biopsies. PCR of duodenal biopsies can also be performed. Central nervous system (CNS) involvement is found in 90% of post-mortem autopsies; yet, overt symptoms develop in only 10–40% of patients. Extended antibiotic courses are often required to prevent relapse; however, relapse can still occur years after proper treatment. Manifestation of relapse usually include mental status changes. Time can range from 1.5 to 12 years and the mean reported time is 4.2 years. Our patient falls within the latter portion in terms of relapse time. In a review of 696 patients with WD, one study noted that only 19 had eye involvement including uveitis, vitritis, retinitis, and retrobulbar neuritis. In another article, among 33 WD patients, 1 had eye involvement. Combination of ocular and CNS involvement in WD like in our patient is uncommon. Clinicians must remain vigilant when patients with history of WD exhibit acute mental status changes after adequate therapy as neurologic involvement can be irreversible.