bluuebunny/crossref_metadata_2025_split huggingface dataset:
2478 Approach to a Foreign Body (Fish Bone) Resulting in a Liver Abscess With Antibiotic-Evading Filamentation of Bacterial Organisms Resembling Fungal Hyphae
Authors: Membreno Raul F. , Pena Miren M. , Chorath Kevin T. , Kang William D. , Membreno Fernando 
Published: October 2019

INTRODUCTION:
Foreign bodies that are ingested may migrate from the gastrointestinal (GI) tract into different organs of the body and cause a variety of clinical manifestations including fever of unknown origin. In this vignette we describe the case of a transmural fish bone migration from the stomach to the liver causing a recurrent liver abscess.

CASE DESCRIPTION/METHODS:
A 76 year old Caucasian male with a past medical history of hypertension presented to the hospital with a left liver lobe abscess that was aspirated six years ago. All cultures at that time were negative and apparently resolved with antibiotics. About two months prior to his hospital admission, he started developing subjective fevers and malaise, with CT Scan of the abdomen showing a possible liver mass in the left lobe. He underwent a liver biopsy of this lesion that showed multiple caseating granulomas. Infectious work up was negative. Despite broad spectrum antibiotics, the patient continued with low grade fevers. Pancultures were negative and a left liver lobectomy and cholecystectomy was pefomed. CT imaging of the liver showed a multiloculated 7.2 cm lesion in the left lobe of the liver consistent with an abscess, with a linear foreign body which extended from the stomach into the left lobe liver lesion (Figure 1). During surgery, the foreign body was identified and removed. Surgical histology of the foreign body showed bone fragments lined by osteocytes and calcifications, which was identified as a “fish bone.” Furthermore, the left liver lobe showed prominent granulomatous inflammation with necrosis and microabscesses with no evidence of malignancy. Special stain GMS-F was positive for filamentous organisms that most closely resembled nocardia or streptomyces (Figure 2).

DISCUSSION:
This is the first case report showing filamentation of bacteria resembling a fungal infection causing a liver abscess due to a fish bone that penetrated the left lobe of the liver. Filamentation is a bacterial defense mechanism against eradication by antibiotics, which explains failure of resolution of the infection with antimicrobials. Studies have reported incomplete bacterial replication leading to the appearance of filamentation resembling fungal species. This phenomenon should be considered by clinicians when treating challenging liver foreign body abscesses.
2504 Successful Budesonide Monotherapy for Autoimmune Hepatitis/Hepatic Sarcoidosis Overlap Syndrome in a Patient With Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) From Azathioprine
Authors: Goff Sara , Liaquat Hammad , Jhala Nirag , Kiyani Amirali 
Published: October 2019

INTRODUCTION:
Drug reaction with eosinophilia and systemic symptoms (DRESS) is considered a severe idiosyncratic drug hypersensitivity which can be fatal if not promptly diagnosed and treated. Here, we describe a case of hepatic sarcoidosis and autoimmune hepatitis (AIH) overlap syndrome who was found to have DRESS from taking azathioprine (AZA).

CASE DESCRIPTION/METHODS:
A 63-year-old African-American female with a diagnosis of AIH and hepatic sarcoidosis overlap based on liver biopsy (chronic hepatitis with moderate activity (grade 2/4), mild fibrosis (stage 1/4), non-caseating granulomata, and interface hepatitis with dense lymphoplasmacytic infiltration) (Figure 1), positive ANA (1:160), and elevated IgG (2140) was started on treatment with AZA and budesonide (intolerance to prednisone). She had normal TPMT activity. Patient stopped taking AZA few days later because of feeling “jittery.” She presented to the ED five weeks later with lip swelling and desquamating rash and was discharged with antihistamines. She returned to the ED two days later with worsening rash, fever, and dyspnea. Labs showed leukocytosis, eosinophilia (56.1%, 13,400/mm3), acute hepatitis, acute kidney injury, and respiratory distress with concern for DRESS. Her initial LFTs were ALT 96, AST 65, and Alk Phos 633, which were increased from her baseline. Imaging ruled out biliary obstruction and bone marrow biopsy was negative for myeloproliferative disorders such as hypereosinophilic syndrome. She was diagnosed with DRESS secondary to AZA and was treated with a short course of prednisone with transition to budesonide monotherapy. Eosinophilia and other organ dysfunction resolved. Her most recent LFTs are ALT 37, AST 42, and Alk Phos 277.

DISCUSSION:
While AZA hypersensitivity syndrome is a well-known disorder presenting with drug eruption and flu-like symptoms, to our knowledge this is the first case of DRESS secondary to AZA. Additionally, this occurred in the setting of hepatic sarcoidosis and AIH overlap syndrome which itself is a rare entity. DRESS is characterized by a long latency time between exposure and disease (2-8 weeks) and presents with end organ dysfunction requiring steroid treatment. Based on the European Registry of Severe Cutaneous Adverse Reactions (RegiSCAR) scoring system, our patient's score was 7, where a score of 6 or higher is considered definite for DRESS. This case also stresses the value of budesonide monotherapy for treating AIH and hepatic sarcoidosis overlap when other first line medications cannot be used.
2507 Amoebic Liver Abscess With Synchronous Proctitis—Presenting With Massive Lower Gastrointestinal Bleeding: A Case Report of a Rare Presentation of Amebiasis
Authors: Nalinthassanai Nutbordee , Chaiteerakij Roongruedee , Sanpavat Anapat 
Published: October 2019

INTRODUCTION:
Amoebic colitis and liver abscess caused by Entamoeba histolytica is one of the most important enteropathogen, leading to 40-73 per 100,000 deaths annually worldwide.1,2 Transmission generally occurs by fecal-oral route and during male homosexual activity.3 Colonic involvement was seen in 58% patients with amoebic liver abscess, but only 7% presents with diarrhea and bleeding.4

CASE DESCRIPTION/METHODS:
A 25-year-old MSM patient with newly diagnosed HIV infection had persistent low grade fever and diarrhea 3-4 times/day for 1 month. He sometimes noticed a small amount of fresh blood in the stool and had mild epigastric discomfort for 1 week. He had worsening abdominal pain, radiating to back and passed 1000 mL fresh blood per rectum. Physical examination showed fever (38.9oC), pallor and markedly enlarged liver with tenderness. Lab showed hemoglobin 6.1 g/dl, white blood cell count 25350 cell/ul (N 89%, L 4%, M 7%), total/direct bilirubin 1.8/1.1 mg/dL, SGOT/SGPT 353/111 U/L, albumin/globulin 2.7/6.6 g/dL, ALP 436 U/L. Colonoscopy showed a 3-cm hemi-circumferential ulcer covered by blood clots and exudative materials with friable mucosa at rectum (Figure 1). Biopsy was done at the ulcer. Abdominal CT showed a 15-cm rim-enhancing cystic lesion with internal septation occupying right liver lobe. Capsule disruption at segment VIII/V anterior aspect of liver was noted (Figure 2). Percutaneous drainage was done and found markedly turbid gray pus 500 ml. Histopathologic findings revealed severe active proctitis with ulcer and few trophozoites ingested red blood cells on the surface, compatible with amoebic proctitis (Figure 3a). The pus aspirated from the abscess showed Charcot Leyden crystals (Figure 3b). Serum for E. histolytica antigen and PCR were both positive. The final diagnosis was amoebic liver abscess with proctitis. The patient was treated with metronidazole for 2 months, with a decreased size of abscess on follow-up CT. No recurrent bleeding occurred.

DISCUSSION:
Although synchronous colonic lesions in amoebic liver abscess are present in over 50% patient, diarrhea and bleeding are uncommon, without unclear reasons. Caecum is the most commonly affected site (70%). Left sided ulcers are seen in elderly and those presenting with diarrhea. Oral or intravenous metronidazole or tinidazole leads to rapid clinical improvement of invasive amoebic colitis and liver abscess. Large abscess (>7.7 cm) with abnormal liver tests were predictive of drainage intervention.
2531 A Bloody Mess: A Rare Cause of Ascites From a Different Field of Medicine
Authors: Simmelink Andrew , Spence Linsey , Brown Jubilee , Kasper Rebecca E. , Scobey Martin 
Published: October 2019

INTRODUCTION:
After exclusion of a traumatic etiology, the development of progressive bloody ascites in a patient usually portends an ominous diagnosis. We present a rare, benign case of progressive bloody ascites due to a gynecologic cause.

CASE DESCRIPTION/METHODS:
A 40 yo healthy African American lady presented with 3 months of worsening abdominal enlargement and nausea. Physical exam and CT scan of the abdomen revealed massive ascites but were otherwise normal. Bloodwork showed a Hgb of 5.7 gm/dL, and normal PLT. Ferritin level, liver panel, hepatitis and HIV studies were all normal. Paracentesis showed 26,000 RBCs, 88 nucleated cells, 79 cholesterol crystals in pigmented macrophages, a SAAG of 0.5, a fluid protein of 5.5 g/dL, and negative cytology. Further testing showed a negative quantiferon-gold along with a normal CEA level and ANA. A CA-125 was mildly elevated at 82 U/mL. CT scan post-paracentesis showed diffusely thickened peritoneum without nodularity, and a 5 cm right pelvic cystic mass. Diagnostic laparoscopy found 4L bloody ascites and complete fibrotic abdominal structure encasement. Peritoneal biopsies and right oophorectomy showed endometriosis. She was treated with a high dose steroid taper and leuprolide with resolution of her ascites.

DISCUSSION:
Our case is one of a few reports describing endometriosis inducing encapsulating peritoneal sclerosis (EPS), and is the first to show asymptomatic endometriosis as the etiology. (EPS) is a syndrome of intestinal obstruction from diffuse thickened peritoneum. Typical symptoms are intermittent abdominal pain with nausea and vomiting related to the intermittent obstruction and reduced gut motility. Symptoms average 3.9 years before diagnosis. Primary EPS is extremely rare and while secondary EPS is usually due to chronic peritoneal dialysis (PD). Other causes include malignancy, infections, and various rheumatologic conditions. Management is based on the offending cause (e.g., stopping PD) but is largely empiric, based on case reports and series utilizing prednisolone and/or tamoxifen.
2551 A Case of Auto-Brewery Syndrome: Probably an Under-Diagnosed Medical Condition
Authors: Malik Fahad , Wickremesinghe Prasanna 
Published: October 2019

INTRODUCTION:
Auto-brewery syndrome (ABS), also known as gut fermentation syndrome, is a rarely diagnosed medical condition in which the ingestion of carbohydrates results in endogenous alcohol production. The patient in this case report had fungal yeast forms in the upper small bowel and cecum, which likely fermented carbohydrates to alcohol. Treatment with antifungal agents allowed subsequent ingestion of carbohydrates without symptoms. He had been exposed to a prolonged course of antibiotics before this occurred. We postulate that the antibiotic altered his gut microbiome, allowing fungal growth.

CASE DESCRIPTION/METHODS:
A healthy 46-year-old male who complained of memory loss, mental changes, and episodes of depression for over three years after antibiotic therapy (cephalexin) for a traumatic thumb injury. He was given a carbohydrate meal and blood alcohol level became elevated to 57 mg/dL without any exogenous alcohol while under observation. Saccharomyces cerevisiae (brewer's yeast) and Saccharomyces boulardii were detected in his stool. To investigate further, an upper and lower endoscopy were performed. Fungal cultures from cecal secretions grew Candida Albicans and Candida Parapsilosis. He was started on a carbohydrate free diet and intravenous micafungin therapy for six weeks after which secretions from a repeat endoscopy showed absence of fungal growth. He was also started on a probiotic to competitively inhibit fungal growth in his gut. A repeat carbohydrate challenge test was negative for endogenous alcohol production now. Approximately 2 years later, he remains asymptomatic and has resumed his previous lifestyle, including eating a normal diet.

DISCUSSION:
A large Middle Eastern study involving 1400 subjects who were teetotalers detected very small endogenously produced alcohol levels using gas chromatography and mass spectrometry. Saccharomyces cerevisiae which can convert carbohydrates to endogenous alcohol, was detected in our patient's stool. This fungus uses acetate for anaerobic alcohol fermentation. It should be noted that the earliest symptoms of ABS may be mood changes, delirium, and brain fog rather than the medical manifestation of alcohol inebriation. A multidisciplinary approach with early psychiatrist involvement is suggested. Any patient denying alcohol ingestion but who has elevated blood alcohol levels or positive breathalyzer results should be investigated for ABS. This could be a treatable condition with dietary modifications, appropriate antifungal therapy and probiotic use.
2619 Persistently Elevated Intestinal Alkaline Phosphatase in an Individual With AB Blood Group: A Rare Presentation
Authors: Mantri Nikhitha , Miranda Jeirym , Jyala Abhilasha , Badipatla Kanthi Rekha , Nayudu Suresh Kumar 
Published: October 2019

INTRODUCTION:
Elevated alkaline phosphatase (ALP) is seen in hepatobiliary and bone diseases. However, elevated intestinal ALP has been reported in the literature in association with blood group B or O, whose clinical significance is not known. We present a rare case of persistently elevated intestinal ALP in an individual with blood group AB.

CASE DESCRIPTION/METHODS:
A 56-year-old female presented to our ambulatory clinic to establish health care. Her medical history included peptic ulcer disease and dyslipidemia. She underwent appendectomy in childhood and cholecystectomy around 20 years ago. she denied smoking, alcohol consumption or use of recreational drugs. Family history was significant for type 1 DM in mother and brother. Her only medication included ranitidine. General and systemic examination was normal. Her initial labs were normal except elevated alkaline phosphatase of 359 units/liter. The patient was seen by the gastroenterology team. Further laboratory workup including viral hepatitis, metabolic and autoimmune markers of liver disease were normal. Gamma-glutamyltransferase (GGT), Vitamin D and parathyroid profile were normal. Ultrasound abdomen did not show any significant lesion in the liver or biliary tree. As no evidence of liver disease was noted isoenzyme electrophoresis of ALP was ordered which showed elevated intestinal ALP fraction of 64% (normal 1–24%). Patient blood group was tested which showed group AB. On further follow up in gastroenterology clinic persistently elevated ALP noted.

DISCUSSION:
Elevated intestinal alkaline phosphatase has been reported in maintaining of gut hemostasis and elevated levels noted in various pathological conditions of the gastrointestinal tract. Meal induced elevation of intestinal ALP has been proposed as a treatment modality to preserve gut hemostasis and minimize inflammation. To the best of our knowledge, our case is an extremely rare presentation of elevated intestinal ALP in an individual with blood group AB. Further molecular and genetic studies in the future may help elaborate functions and therapeutic intervention of intestinal ALP
2629 A Benign Tumor With a Malignant Course
Authors: Zackria Rasiq , Hwang Andrew W. 
Published: October 2019

INTRODUCTION:
Mesenteric fibromatosis is a rare, locally invasive, non-metastasizing intra-abdominal fibroma with a high rate of recurrence. These tumors pose a diagnostic and therapeutic challenge due to its rarity and wide-ranging clinical presentation.

CASE DESCRIPTION/METHODS:
A 43-year-old man with a medical history of hypertension and no prior surgeries who presented with acutely worsening diffuse abdominal pain with associated bloating, nausea, and vomiting for 2 days. Physical exam revealed abdominal tenderness with deep palpation with the absence of peritoneal signs. MRI revealed a large liver mass with central necrosis suspicious of hepatocellular carcinoma, however, the biopsy was consistent with a hemangioma. Colonoscopy visualized a colonic mass with difficulty maneuvering the scope through the entire colon raising concern for primary versus metastatic colon cancer. Tumor markers were unremarkable. Gastrografin radiography demonstrated a high-grade obstructing annular mucosal lesion at the splenic flexure. He underwent left hemicolectomy with colostomy placement. Pathology demonstrated a spindle cell neoplasm with a fascicular architecture surrounded by abundant collagen fibers with no necrosis. Further histological staining was positive for vimentin, beta-catenin, and desmin conforming to mesenteric fibromatosis.

DISCUSSION:
Mesenteric fibromatosis is part of the clinical-pathologic spectrum of deep fibromatosis encompassing a group of benign fibroproliferative processes that are locally aggressive and have the capacity to infiltrate or recur, but not metastasize. Most cases manifest sporadically, however, there is a link with familial adenomatous polyposis (FAP), specifically Gardner syndrome. In addition, they can be locally aggressive showing recurrence even after excision. Mesenteric fibromatosis may be confused radiologically and histologically with a gastrointestinal stromal tumor (GIST), however immunohistochemical profile is helpful in differentiation. Mesenteric fibromatosis is typically negative for CD34 and CD117, which are almost universally positive in GISTs. This case illustrates the difficulty in diagnosing mesenteric fibromatosis, and a secondary lesion can complicate diagnosis. Mesenteric fibromatosis with intestinal involvement can be easily confused with other primary gastrointestinal tumors, especially with mesenchymal origin such as GIST. Hence, it should be considered in the differential diagnosis of mechanical intestinal obstruction as well as intra-abdominal masses.
2662 A Unique Presentation of Concurrent Duodenal and Peritoneal Metastasis From Head and Neck Cancer
Authors: Ahmed Ahmed , Nasir Umair M. , Delle Donna Paul , Ahmed Shahida , Lenza Christopher 
Published: October 2019

INTRODUCTION:
It is very rare for head and neck squamous cell carcinoma (HNSCC) to metastasize to the duodenum or the peritoneum. Only a few cases have been reported for each metastatic site, however, there have been no reported cases of concurrent duodenal and peritoneal metastasis (PM) from HNSCC. Such a presentation enhances the literature on HNSCC and illustrates the need for further studies to understand the mechanism of HNSCC metastasis.

CASE DESCRIPTION/METHODS:
68-year-old male with history of HNSCC presented with worsening nausea, postprandial vomiting, and abdominal pain for over 2 months. 3 months prior he was worked up for several postauricular lumps, with computerized tomography (CT) scan showing a supraglottic mass and excisional biopsy of a nodule confirming metastatic HNSCC. Imaging upon admission showed new peritoneal carcinomatosis and worsening diffuse lymphadenopathy (LAD). Esophagogastroduodenoscopy (EGD) showed a large nodular lesion occupying one third of the lumen circumference. Like the neck nodule, biopsies of the mass showed metastatic, poorly differentiated SCC that was strongly positive for p63 and p16. The patient was not deemed a candidate for chemotherapy due to poor prognosis and poor functional status and was eventually discharged on home hospice.

DISCUSSION:
We hereby described the first case of concurrent duodenal and peritoneal metastasis from a HNSCC, with both being independently rare sites of metastasis. The patient’s history of chronic tobacco use increased his risk of SCC. Chemotherapy and peritoneal excision, in certain cases, have shown to be a viable treatment option and have a beneficial impact on survival and quality of life. In select cases of obstruction, palliative stenting can be an option to improve quality of life. Due to rapid disease progression and the patient’s poor functional status, these treatment options were deemed not feasible. There are many speculated mechanisms regarding intestinal and PM such as direct extension, tumor rupture or trauma leading to seeding of the peritoneum, hematogenous dissemination, and even via the lymphatics. In our case, the patient did not have any abdominal surgeries and had multiple metastatic sites, including the duodenum, making hematogenous or lymphatic spread more likely. In any case, further studies are needed to understand the mechanism involved in HNSCC metastasis.
2670 A Highly Lethal Case of Gastric Pneumatosis
Authors: Multani Monica , Kantor Micaella , Anyu Tse , Sobrado Javier 
Published: October 2019

INTRODUCTION:
While gas can accumulate in the intestinal wall at multiple sites, the stomach is the rarest site because of its acidity and very efficient mucosal barrier. In has been proposed in one retrospective study that 46% of their cases involved the colon, 27% the small bowel, 14% in whom the whole gastrointestinal tract was infected including the portal venous system, 7% the small bowel with the colon, and only 5% the stomach as in our case.

CASE DESCRIPTION/METHODS:
An 83 year old male with history of coronary artery disease, diabetes mellitus, bullous pemphigoid and smoking history presented for shortness of breath over one week. Patient was tachypnic and using accessory muscles on exam. During his hospital course, he had abdominal pain. CT Scan showed fluid filled distal esophagus, distended stomach, air-fluid levels and peripheral lucencies concerning for intramural gas. Nasogastric tube put out a large amount of red emesis after which he expired.

DISCUSSION:
There are two distinct pathological processes involved in air within the lumen of the stomach which is termed gastrointestinal pneumatosis. The first type is called gastric emphysema which often has a benign course and constitutes 9% of all gastrointestinal pneumatosis cases. Gastric emphysema is classified as traumatic, pulmonary or obstructive types. There have only been 5 recorded cases of gastric emphysema with a pulmonary etiology and four of those cases were secondary to bullous emphysema. The second type is emphysematous gastritis which involves gas forming organisms including Pseudomonas aeruginosa, Candida albicans, and Staphylococcus aureus. The risk factors for this dangerous type of gastrointestinal pneumatosis include a history of abdominal surgery or manipulation, bowel infarction/ischemia, immunosuppression which include disease processes including diabetes, alcohol abuse or corrosive material ingestion. There is a mortality of 16% in those receiving surgical treatment versus 6% who received only conservative treatment. In stable patients, improvement in clinical condition or emphysema resolution within 3 days occurs with nasogastric catheter decompression as attempted in our case. This becomes important in identifying between gastric emphysema, a relatively benign course, or emphysematous gastritis, which has a poor prognosis. As time becomes an increasingly prognostic factor for these individuals, differentiation in treatments based on type could lead to faster implementation which could ultimately help to prevent demise.