Giardiasis and Eosinophilia in Outpatients with Gastrointestinal Symptoms: A Case Series

Hypogammaglobulinemia, a form of primary immunodeficiency, is an uncommon condition. Gastrointestinal (GI) symptoms may be the only presentation. A series of 22 patients who presented with GI symptoms and were diagnosed with hypogammaglobulinemia is presented. Chronic diarrhea was the presentation in majority (90.9%) of patients. Malabsorption was identified in 87.5% of patients followed by weight loss (59.0%), abdominal pain (27.2%), and oral ulcers (4.5%). The median duration of symptoms prior to diagnosis was 4years, range being 6months to 23years. Evaluation revealed opportunistic infections including Giardia lamblia in 31.8% and Cryptosporidium parvum, Isospora belli, Cytomegalovirus and Aeromonas in 4.5% each. Serum globulins were low in all patients. Duodenal biopsy showed paucity of plasma cells in 45%, villous atrophy in 35% and nodular lymphoid hyperplasia in 30% patients. Though uncommon, hypogammaglobulinemia is associated with GI disease. The possibility of a primary immunodeficiency should be considered in patients presenting with GI symptoms and low serum globulin.

COVID-19 in Kidney Transplantation: Outcomes, Immunosuppression Management, and Operational Challenges.

BackgroundIn general, children with COVID-19 have milder illness and better prognosis compared to adults. However, the neonatal population (from birth to 28 days of life) may be more vulnerable to...

Systematic analysis of acute liver injury during SARS-CoV-2 infection

Multiple Food Protein Intolerance of Infancy or Severe Spectrum of Non-IgE-Mediated Cow's Milk Allergy? - a Case Series

This translational research case series describes the implementation of a gastrointestinal assessment protocol during exercise (GastroAxEx) to inform individualised therapeutic intervention of endurance athletes affected by exercise-induced gastrointestinal syndrome (EIGS) and associated gastrointestinal symptoms (GIS). A four-phase approach was applied. Phase 1: Clinical assessment and exploring background history of exercise-associated gastrointestinal symptoms. Phase 2: Individual tailored GastroAxEx laboratory simulation designed to mirror exercise stress, highlighted in phase 1, that promotes EIGS and GIS during exercise. Phase 3: Individually programmed therapeutic intervention, based on the outcomes of Phase 2. Phase 4: Monitoring and readjustment of intervention based on outcomes from field testing under training and race conditions. Nine endurance athletes presenting with EIGS, and two control athletes not presenting with EIGS, completed Phase 2. Two athletes experienced significant thermoregulatory strain (peak core temperature attained > 40°C) during the GastroAxEx. Plasma cortisol increased substantially pre- to post-exercise in n = 6/7 (Δ > 500 nmol/L). Plasma I-FABP concentration increased substantially pre- to post-exercise in n = 2/8 (Δ > 1,000 pg/ml). No substantial change was observed in pre- to post-exercise for systemic endotoxin and inflammatory profiles in all athletes. Breath H2 responses showed that orocecal transit time (OCTT) was delayed in n = 5/9 (90–150 min post-exercise) athletes, with the remaining athletes (n = 4/9) showing no H2 turning point by 180 min post-exercise. Severe GIS during exercise was experienced in n = 5/9 athletes, of which n = 2/9 had to dramatically reduce work output or cease exercise. Based on each athlete’s identified proposed causal factors of EIGS and GIS during exercise (i.e., n = 9/9 neuroendocrine-gastrointestinal pathway of EIGS), an individualised gastrointestinal therapeutic intervention was programmed and advised, adjusted from a standard EIGS prevention and management template that included established strategies with evidence of attenuating EIGS primary causal pathways, exacerbation factors, and GIS during exercise. All participants reported qualitative data on their progress, which included their previously presenting GIS during exercise, such as nausea and vomiting, either being eliminated or diminished resulting in work output improving (i.e., completing competition and/or not slowing down during training or competition as a result of GIS during exercise). These outcomes suggest GIS during exercise in endurance athletes are predominantly related to gastrointestinal functional and feeding tolerance issues, and not necessarily gastrointestinal integrity and/or systemic issues. GastroAxEx allows for informed identification of potential causal pathway(s) and exacerbation factor(s) of EIGS and GIS during exercise at an individual level, providing a valuable informed individualised therapeutic intervention approach.

AGA Rapid Recommendations for Gastrointestinal Procedures During the COVID-19 Pandemic

COVID-19 and the Gastrointestinal System: What Trainees Need to Know.

1. Raymond Cai, MD* 2. Vikram Bhise, MD† 1. *Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 2. †Department Neurology and Pediatrics, Robert Wood Johnson University Hospital, New Brunswick, NJ I spent a week with medical students and family medicine residents in northeast Africa earlier this year. There, bright, clinically astute trainees at a major university use Pediatrics in Review as a core foundation of their pediatric curriculum. Wherever you are in the world this month, may these Index of Suspicion cases help you advance your knowledge and practice of pediatrics. Philip R. Fischer, MD Associate Editor, Index of Suspicion A 13-year-old girl presented to the emergency department with acute onset of lower extremity weakness. She first awoke with dizziness but soon developed severe back pain, bilateral lower extremity pain and numbness, slurred speech, and inability to move her lower extremities or ambulate. She reports having a 2-day history of headaches and back pain. Due to worsening of her symptoms, she went to an urgent care center the previous day. A rapid viral test showed she was influenza positive, and she took 2 doses of oseltamivir before admission. The patient had an upper respiratory tract infection approximately 2 to 3 weeks ago. In the emergency department, the patient is unable to void spontaneously despite being able to at home, and a urinary catheter is placed. On physical examination her vital signs are as follows: temperature, 98.6°F (37.0°C); heart rate, 77 beats/min; respiratory rate, 20 breaths/min; and blood pressure, 119/74 mm Hg. Her BMI was within the 75th to 85th percentile. Her lower extremities bilaterally had 1/5 strength, diminished sensation to pinprick and temperature, and 0/5 patellar reflexes. She also had a 0/5 right Achilles reflex but a 1/5 …

To describe presentation, hospital course, and predictors of bad outcome in multisystem inflammatory syndrome in children (MIS-C). Retrospective data review of a case series of children meeting the published definition for MIS-C who were discharged or died between March 1, 2020, and June 15, 2020, from 33 participating European, Asian, and American hospitals. Data were collected through a Web-based survey and included clinical, laboratory, electrocardiographic, and echocardiographic findings and treatment management. We included 183 patients with MIS-C: male sex, 109 (59.6%); mean age 7.0 ± 4.7 years; Black race, 56 (30.6%); obesity, 48 (26.2%). Overall, 114 of 183 (62.3%) had evidence of severe acute respiratory syndrome coronavirus 2 infection. All presented with fever, 117 of 183 (63.9%) with gastrointestinal symptoms, and 79 of 183 (43.2%) with shock, which was associated with Black race, higher inflammation, and imaging abnormalities. Twenty-seven patients (14.7%) fulfilled criteria for Kawasaki disease. These patients were younger and had no shock and fewer gastrointestinal, cardiorespiratory, and neurologic symptoms. The remaining 77 patients (49.3%) had mainly fever and inflammation. Inotropic support, mechanical ventilation, and extracorporeal membrane oxygenation were indicated in 72 (39.3%), 43 (23.5%), and 4 (2.2%) patients, respectively. A shorter duration of symptoms before admission was found to be associated with poor patient outcome and for extracorporeal membrane oxygenation and/or death, with 72.3% (95% confidence interval: 0.56-0.90; P = .006) increased risk per day reduction and 63.3% (95% confidence interval: 0.47-0.82; P < .0001) increased risk per day reduction respectively. In this case series, children with MIS-C presented with a wide clinical spectrum, including Kawasaki disease-like, life-threatening shock and milder forms with mainly fever and inflammation. A shorter duration of symptoms before admission was associated with a worse outcome.

BACKGROUNDA large number of pneumonia cases due to coronavirus disease 2019 (COVID-19) have been first reported in China. Meanwhile, the virus is sweeping all around the world and has infected millions of people. Fever and pulmonary symptoms have been noticed as major and early signs of infection, whereas gastrointestinal symptoms were also observed in a significant portion of patients. The clinical investigation of disease onset was underestimated, especially due to the neglection of cases presenting with gastrointestinal symptoms.AIMTo characterize the clinical features of coronavirus-infected patients with gastrointestinal symptoms as initial symptoms.METHODSThis is a retrospective, single-center case series of the general consecutive hospitalized patients with confirmed COVID-19 at Wuhan Union Hospital from February 2, 2020 to February 13, 2020. According to their initial symptoms, these patients were classified into two groups. Patients in group one presented with pulmonary symptoms (PS) as initial symptoms, and group two presented with gastrointestinal symptoms (GS). Epidemiological, demographic, clinical, laboratory, and treatment data were collected for analysis.RESULTSAmong the 50 patients recruited, no patient has been admitted to intensive care units, and no patient died during the study. The duration of hospitalization was longer in the GS group than in the PS group (12.13 ± 2.44 vs 10.00 ± 2.13, P < 0.01). All of the 50 patients exhibited decreased lymphocytes. However, lymphocytes in the GS group were significantly lower compared to those in the PS group (0.94 ± 0.06 vs 1.04 ± 0.15, P < 0.01). Procalcitonin and hs-CRP were both significantly higher in the GS group than in the PS group. Accordingly, the duration of viral shedding was significantly longer in the GS group compared to the PS group (10.22 ± 1.93 vs 8.15 ± 1.87, P < 0.01).CONCLUSIONCOVID-19 patients presenting with gastrointestinal symptoms as initial symptoms need more days of viral shedding and hospitalization than the patients presenting with pulmonary symptoms.

Haws syndrome (HS) in cats is characterized by bilateral protrusion of the third eyelid and ptosis, often accompanied by gastrointestinal (GI) symptoms such as diarrhea. Emerging evidence suggests disruption of the gut-brain axis, linked to GI microbiota dysbiosis, may play a role in HS development. To describe the clinical features and outcomes of five cats with HS managed with a gastrointestinal diet targeting presumed dysbiosis. This study included five cats diagnosed with spontaneous HS. Each cat underwent thorough ophthalmic and physical examinations, as well as fecal Giardia testing and pharmacological testing with 1% phenylephrine. All cats were managed with Hill's Gastrointestinal Biome diet for 3 months. Ocular signs transiently resolved following topical administration of 1% phenylephrine, indicating sympathetic neuropathy. Physical examinations were unremarkable, except for diarrhea in 3/5 cats. Fecal tests for Giardia were initially positive in 4/5 cats and became negative in 3 upon recheck. GI symptoms resolved within 4 to 14 days in 2/3 cats with diarrhea, although only partial improvement was noted in one. Ocular signs resolved in all cats within 11 to 39 days and did not recur during the follow-up period of 327 to 438 days. The improvement in ocular and GI signs following dietary management with a prebiotic-enriched gastrointestinal diet suggests that this approach may be beneficial for cats with HS, potentially by addressing underlying GI microbiota dysbiosis. However, it may be insufficient in refractory cases or when GI symptoms do not fully resolve.

Most people with coronavirus disease 2019 (COVID-19) experience resolution of symptoms within days to weeks following initial infection. In a subset of individuals, symptoms persist longer than 4 weeks, known as 'Long COVID'. Many gastrointestinal (GI) symptoms persist as part of this syndrome; yet, an approach to treatment remains unclear. Prior studies have demonstrated the efficacy of complementary and alternative medicine (CAM) for the treatment of acute COVID-19 infections, but little data exist regarding the potential use of CAM in the treatment of Long COVID. Identify CAM approaches useful in treating the GI symptoms of Long COVID. A systematic review of studies reporting on the use of CAM for the treatment of GI symptoms of Long COVID was performed. Five electronic databases were searched from January 2019 to November 2022. Studies describing the use of CAM to treat GI symptoms of Long COVID were included and assessed by two independent reviewers. Studies not reporting on GI symptoms or using CAM were excluded. Studies chosen for final review underwent quality and bias assessment using predetermined criteria. The extracted data were synthesized utilizing a framework derived from the National Center of Complementary and Integrative Health categories. The initial search yielded 396 articles. After applying the eligibility criteria, a total of four studies (three case reports and one case series) were included for final review. Two studies used nutritional supplements and two studies used traditional Chinese medicine. Reductions in nausea, loss of appetite, diarrhea, acid reflux, epigastric pain, and bloating were reported. This is the first systematic review to explore the role of CAM in treating GI manifestations of Long COVID. The review identified four studies, all reporting reductions in the GI symptoms of Long COVID. Despite the positive studies included in this review, the overall search yielded few results, all of which were non-experimental. As the post-infectious sequelae of COVID-19 become better recognized in the wake of the pandemic, higher-quality clinical studies are needed.

Human colonic spirochetosis (CS) is usually due toBrachyspira pilosicolior Brachyspira aalborgiinfection. While traditionally considered to be commensal bacteria, there are scattered case reports and case series of gastrointestinal (GI) symptoms in CS and reports of colonic polyps with adherent spirochetes. We performed a systematic review and meta‐analysis investigating the association between CS and GI symptoms and conditions including the irritable bowel syndrome (IBS) and colonic polyps. Following PRISMA 2020 guidelines, a systematic search of Medline, CINAHL, EMBASE, and Web of Science was performed using specific keywords for CS and GI disease. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random‐effects model. Of 75 studies identified in the search, 8 case–control studies met the inclusion criteria for meta‐analysis and 67 case series studies met the inclusion criteria for pooled prevalence analysis. CS was significantly associated with diarrhea (n = 141/127, cases/controls, OR: 4.19, 95% CI: 1.72–10.21, P = 0.002) and abdominal pain (n = 64/65, OR: 3.66, 95% CI: 1.43–9.35, P = 0.007). CS cases were significantly more likely to have Rome III‐diagnosed IBS (n = 79/48, OR: 3.84, 95% CI: 1.44–10.20, P = 0.007), but not colonic polyps (n = 127/843, OR: 8.78, 95% CI: 0.75–103.36, P = 0.084). In conclusion, we found evidence of associations between CS and both diarrhea and IBS, but not colonic polyps. CS is likely underestimated due to suboptimal diagnostic methods and may be an overlooked risk factor for a subset of IBS patients with diarrhea.

Background: Various digestive symptoms have been frequently reported in a significant portion of patients infected with the virus since the outbreak of Coronavirus Disease 2019 (COVID-19). Most patients with COVID-19 have a fever accompanied by respiratory signs and symptoms, such as cough and dyspnea. We present 36 cases with a chief complaint of Gastrointestinal (GI) symptoms along with respiratory symptoms. In this study, we aimed at investigating the prevalence and outcomes of COVID-19 patients with digestive symptoms. Methods: A variety of observed GI symptoms included nausea and vomiting (72.2%), diarrhea (25%), abdominal pain (19.4%), loss of appetite (14%), and anosmia (14%). The most nonGI symptoms were dyspnea (66.7%), fever (66.7%), dry cough (58.3%), myalgia (52.4%), and others. Six patients (16.6%) were critically ill, 7 (19.4%) were in stable condition, and 23 patients (64%) showed moderate symptoms. Among the patients, 7 (19.5%) needed critical care and were admitted to ICU. Leucopenia, lymphopenia, and elevated acute-phase proteins were other features observed in these patients. The most common antiviral regimen was hydroxychloroquine and oseltamivir. Finally, 32 patients (89%) were discharged, and 4 (11%) died. Conclusion: This case series study highlights that patients with COVID-19 are prone to GI symptoms along with fever and respiratory symptoms. Patients may even present with digestive symptoms and without any respiratory symptoms. Hence, clinicians should pay more attention to these patients and help diagnose COVID-19 earlier to start prompt treatment before the occurrence of severe disease.