Diagnostic Dilemma Research Articles

A295 A CHALLENGING DIAGNOSTIC CASE - SEVERE ACUTE HEPATITIS POTENTIALLY ASSOCIATED WITH COVID-19 IN AN IMMUNOCOMPETENT YOUNG ADULT

Abstract Background Severe hepatitis with liver enzymes in the thousands is usually associated with viral etiologies, toxins, vascular aetiologies, acute gall stones, autoimmune hepatitis, and Wilson disease. Acute hepatitis in the moderate range has been associated with COVID19 infection. Aims A potential case of severe hepatitis with initial ALT of 6863, who tested positive for COVID19. Acetaminophen ingestion confounded the presentation. Methods Case Report Results A 48-year-old woman, with history of Insomnia on Zopiclone, presented to Hospital with a 6-day history of fatigue, malaise, muscle aches and subjective fevers. She had a ten pack-years smoking history, consumed 8 alcoholic beverages weekly, used marijuana infrequently, and denied any herbal or naturopathic supplement usage. She was double vaccinated against COVID19 over a year ago. On the 2nd day of symptoms, she ingested 5 grams of Acetaminophen over a 24-hour period. Subsequently, she continued to use Acetaminophen, but did not exceed a daily dosage of 4 grams. On the 5th day, she presented to clinic and was found to have elevated liver enzymes: ALT 6863, AST 5785, ALP 62, GGT 60, and INR 1.1 with Bilirubin 8. She had nausea and emesis, prompting her to present to the hospital on the 6th day. The patient was alert and oriented, with mild tenderness in the right upper quadrant with no jaundice, ascites, peripheral edema, or encephalopathy. She had reactive lymphocytosis consistent with a potential viral infection. Testing for acute hepatitis A, B, and C, HIV, EBV, CMV, herpes simplex virus, and varicella-zoster was negative. COVID19 was detected by rapid antigen testing and confirmed via PCR. Blood and urine toxicology screens were unremarkable. Acetaminophen was detected at a low level of 67 μg/mL at presentation and given the diagnostic dilemma & concern for concomitant acetaminophen-associated liver injury she was started on N-acetylcysteine (NAC) infusion. Acetaminophen level was trended until undetectable. Ceruloplasmin and alpha-1 antitrypsin were unremarkable. Iron studies showed an elevated Ferritin 1032. Autoimmune workup was negative except for anti-dense fine speckled autoantibodies with 1:80 (low) titre. Abdominal ultrasound with doppler was normal. Her liver enzymes improved (Figure1) without signs of acute fulminant liver failure. She was discharged after 48 hours (day 7). In follow-up, her labs were: ALT 11, AST 16, INR 1.1, Bilirubin 6, and Ferritin 61. Conclusions To our knowledge, this is one of the first case reports of severe hepatitis, possibly due to COVID-19 in an immunocompetent adult, however, concerns for concomitant unintentional acetaminophen toxicity complicate the diagnosis. NAC was given to mitigate diagnostic error given the risk of anchoring bias. If patient condition had deteriorated liver biopsy would have been considered. Funding Agencies None

A234 DOES FECAL CALPROTECTIN CORRELATE WITH INFLAMMATION ON ULTRASOUND IN CROHN’S DISEASE STRICTURES?

Abstract Background Fibrostenotic Crohn’s Disease (CD) is a challenging phenotype particularly due to the absence of intestinal anti-fibrotic therapies. Differentiating between strictures that are predominantly fibrotic as opposed to inflammatory remains a diagnostic dilemma. The ability to make this differentiation is critical to inform decisions for therapeutic approach. Fecal calprotectin (FC) is a stool marker reflective of intestinal inflammation. Very few studies have evaluated the relationship of FC concentration in ileal CD strictures and parameters of inflammation on intestinal ultrasound (IUS). Strictures on imaging are defined as 1) increased bowel wall thickness (BWT), 2) narrowed luminal apposition, and 3) pre-stenotic dilation (PSD). BWT and hyperemia (color Doppler signal (CDS)) are the most sensitive markers for CD inflammation on IUS. It is predicted that FC will match CDS in ileal strictures, similar to non-stricture phenotypes. Aims We aim to correlate FC levels with IUS inflammation of ileal CD strictures. Methods We performed a retrospective cohort pilot study exploring the relationship between FC levels and IUS inflammatory parameters in ileal strictures. FC levels were obtained ≤ 60 days of index IUS in fibrostenotic ileal CD patients. Individuals who underwent medication changes or experienced a clinical flare during this period were excluded. Inflammation was measured as BWT and CDS using a modified Limberg (ML) score. Pearson correlation for continuous variables, Spearman rank correlation and a Kruskal-Wallis test for FC and Limberg scale were completed. Results A total of 25 fecal samples were obtained from 17 patients with ileal strictures (47% male, median age 59 years (range 18-76)) were assessed. Median FC concentrations was 204.9 ug/g, IQR: 250.4. Median ileal stricture BWT was 7.0 mm (range 3.0–10.0). 40% (10/25) had ML1 (short chains in bowel), 32% (8/25) ML2 (long chains in bowel), and 28% (7/25) ML3 (long chains and perienteric fat). There was no correlation between FC and BWT (r= .02, p = 0.92), nor FC with ML scores (r=0.20, p= 0.25). In those with ML1, median FC was 232.4, while those with ML2 or 3, had a FC of 155.6 and 469.7, respectively. FC values were significantly different between the ML scores, pampersand:003C0.0001. Conclusions FC levels were not correlated with inflammatory parameters as seen on IUS in ileal CD. This unexpected finding may be due to ML2 scores having lower FC than anticipated, and small sample size. Other imaging factors such as loss of wall stratification need to be taken into account, and are perhaps more reflective of inflammation than BWT and CDS. This study provides the initial data to assess accuracy of FC and hyperemia of ileal CD strictures on IUS compared to histologic measures of inflammation on resected specimens. Funding Agencies None

A159 MALIGNANT PERITONEAL MESOTHELIOMA: A CASE OF MISTAKEN IDENTITY

Abstract Background In the Western hemisphere, cirrhosis is the most common cause of ascites. One of the least common causes is malignant peritoneal mesothelioma (MPM), which occurs in one in one million cases. MPM can be a diagnostic challenge due to its rarity and features that mimic other causes of ascites. Aims To describe a complex case of MPM, highlighting the diagnostic dilemma stemming from the subtleties of presentation, confounders in ascites diagnostic criteria, and indeterminate testing. Methods We performed a detailed retrospective chart review of a patient who presented with ascites. He was initially given the diagnosis of decompensated cirrhosis and eventually was diagnosed with MPM. He provided his consent for this case report. Results A 37-year-old male presented with progressive ascites and peripheral edema. He had no known exposure to asbestos and consumed 6 standard drinks a day for 2 years; with a prior history of 10 standard drinks a week for over 3 years. His physical examination was unremarkable for cardiac, renal or liver disease. His transthoracic echocardiogram and urinalysis were normal. Abdominal ultrasound showed features of liver cirrhosis with large-volume ascites and a FIB-4 score of 0.34, excluding advanced fibrosis Laboratory investigations including liver tests were normal; with a platelet count of 568 x 109/L. Viral, metabolic and autoimmune liver disease were excluded. A diagnostic paracentesis demonstrated a serum albumin-ascites gradient (SAAG) of 1.3 g/dL. Due to his history of alcohol misuse, imaging findings and high SAAG, he was diagnosed with alcohol-related cirrhosis. His repeat abdominal ultrasound showed multiple liver nodules. Magnetic resonance imaging was done to investigate for hepatocellular carcinoma; revealing diffuse peritoneal carcinomatosis, cirrhosis and large-volume ascites. Investigations to identify the primary malignancy included a computed tomography chest, colonoscopy and EGD. His EGD was the only positive test; showing a 2cm submucosal gastric lesion with normal gastric mucosa pathology. An endoscopic ultrasound (EUS) with fine needle aspiration was then performed; the lesion appearance in keeping with a gastrointestinal stromal tumor (GIST). Pathology favored a diagnosis of poorly differentiated gastric carcinoma. Cytology was positive for malignancy, with the differential being mesothelioma or adenocarcinoma and a repeat SAAG was 1.0 g/dL. Given the discordances, an ultrasound-guided core biopsy was performed of the peritoneal lesions. Pathology revealed features of poorly differentiated epithelioid mesothelioma. A subsequent review of his gastric biopsies revealed similar cells in retrospect were in keeping with mesothelioma. Conclusions The presentation of MPM is not easily distinguishable from other causes of ascites. There must be a high degree of suspicion for malignant ascites in the face of inconsistent clinical and diagnostic findings. Funding Agencies None

Immunohistochemical expression of H3.3 G34W in 100 giant cell tumors of bone and its diagnostic mimics, including its value in resolving uncommon diagnostic scenarios: A single institutional study at a tertiary cancer referral center, India.

There can be a diagnostic challenge in differentiating giant cell tumor of bone (GCTB) from its mimics. Lately, histone H 3 F 3 A (Histone 3.3 ) G34W has been identified as a promising immunohistochemical marker. This study was aimed at evaluating H3.3 G34W immunostaining in 100 GCTBs, including its value in resolving diagnostic dilemmas. Immunohistochemical staining for H3.3 G34W was graded in terms of staining intensity (1+ to 3+) and the percentage of tumor cells showing crisp nuclear staining. One hundred GCTBs occurred in 58 males and 42 females (M: F ratio = 1.3), of 7-66 years age (average = 31.3, median = 28), commonly in distal femur (26), followed by proximal tibia (17), distal radius (12), proximal humerus (7), metacarpals (7), sacrum (6), proximal fibula (6), and relatively unusual sites (19), including a single multicentric case. Out of 92 GCTBs, wherein H3.3 G34W immunostaining worked, 81 (88.1%) showed positive staining in the mononuclear cells, including tumors with fibrous histiocytoma-like areas, sparing osteoclast-like giant cells, with 3+ staining intensity in 65/81 (80%) tumors. All 7/7 (100%) malignant GCTBs showed positive staining, including the pleomorphic/sarcomatous cells. All 7/7 (100%) metastatic GCTBs showed positive immunostaining. Seven out of 10 post-denosumab treated GCTBs showed positive H3.3 G34W immunostaining in the residual mononuclear cells. None of the other 37 "giant cell-rich" lesions displayed H3.3 G34W immunostaining. Four of 9 GCTBs tested for H3.3 G34W mutation showed positive results. The diagnostic sensitivity and specificity of H3.3 G34W for GCTB were 88.1% and 100%, respectively. This constitutes one of the first reports from our country, further validating the diagnostic value of H3.3 G34W in differentiating GCTB, including metastatic and malignant forms from its mimics, including small biopsy samples. Its value in various diagnostic dilemmas is presented and utility in identifying residual tumor cells in post-denosumab treated GCTBs is worth exploring.

Clinical Feature of Langerhans Cell Histiocytosis of the Orbit : A First Case Series in Indonesia

Introduction : Langer hans histiocytosis (LCH) is an inexplicable disease characterized by proliferation of Langerhans and intermixed with inflammatory cell, in particular eosinophil, which represents only 1% pediatric orbital tumours. Orbital involvement of LCH is a rare clinical entity as the disease simulate variety of malignancies and present as a diagnostic and management dilemma for ophthalmologist.
 Case Illustration : Two cases of toddler presented with unilateral progressive upper eyelid swelling and proptosis for more than a month. Both cases has history of orbital trauma 1 month before swelling was observed. Initial CT scan revealed extraconal mass, with destruction of lateral orbital wall and frontal bone. Both patients had histopathological biopsy confirmed eosinophlic cytoplasm. One patient confirmed immunohistochemistry markers S100 and CD1a which is specific for Langerhans cells. Both patients continue with chemotherapy as definitive treatment.
 Discussion : LCH is a wide clinical spectrum which manifestation simulate other pediatric orbital malignancies. Case illustration present unilateral eyelid swelling with history of trauma may resemble other diagnosis unless further work up is performed. This case series exhibits clinical manifestations that may be suggestive of LCH. Considering rapid progression of disease, definitive diagnosis is a mandatory based on histopatological analysis through biopsy surgery.
 Conclusion : LCH is rare disease, it should be considered as one of deferential diagnosis in pediatric orbital malignancy with initial presentation acute unilateral eyelid swelling, proptosis, history of trauma, extraconal mass and destruction of bones as radiological features. This might be helpful for early recognition and prompt treatment of disease suggestive of LCH.

Erythema Multiforme-Oral Variant: Case Report

Erythema multiforme (EM) is an interesting dermatologic disease which has oral manifestations. EM is clinically characterized by a “minor” form and a “major” form. It presents a diagnostic dilemma because the oral cavity has the ability to produce varied manifestations. Infections (particularly herpes simplex and mycoplasma pneumonia) and drugs seem to predispose toward the development of EM. The range of possible etiologies for oral disease is immense. Therefore, an otolaryngologist or a dentist while treating such patients should have a differential diagnosis for all oral lesions. We report a case of erythema multiforme in which alcohol (ethanol) seems to be the precipitating factor and have also reviewed the English literature in the present context.

Infrequent Presentations of Chronic NPM1-Mutated Myeloid Neoplasms: Clinicopathological Features of Eight Cases from a Single Institution and Review of the Literature.

Non-acute myeloid neoplasms (MNs) with NPM1 mutations (NPM1mut-MNs) pose a diagnostic and therapeutic dilemma, primarily manifesting as chronic myelomonocytic leukemia (CMML) and myelodysplastic syndromes (MDS). The classification and treatment approach for these conditions as acute myeloid leukemia (AML) are debated. We describe eight cases of atypical NPM1mut-MNs from our institution and review the literature. We include a rare case of concurrent prostate carcinoma and MN consistent with chronic eosinophilic leukemia, progressing to myeloid sarcoma of the skin. Of the remaining seven cases, five were CMML and two were MDS. NPM1 mutations occur in 3-5% of CMML and 1-6% of MDS, with an increased likelihood of rapid evolution to AML. Their influence on disease progression varies, and their prognostic significance in non-acute MNs is less established than in AML. Non-acute MNs with NPM1 mutations may display an aggressive clinical course, emphasizing the need for a comprehensive diagnosis integrating clinical and biological data. Tailoring patient management on an individualized basis, favoring intensive treatment aligned with AML protocols, is crucial, regardless of blast percentage. Research on the impact of NPM1 mutations in non-acute myeloid neoplasms is ongoing, requiring challenging prospective studies with substantial patient cohorts and extended follow-up periods for validation.

Lacrimal sac Aspergillosis Masquerading as Malignancy: A Rare Case Report.

Invasive fungal infections are uncommon in an immunocompetent host and pose a real diagnostic dilemma. As they have a propensity for locoregional destruction, clinic-radiological findings can mislead to a faulty diagnosis of a malignancy. Here we present a case of Primary Aspergillus dacryocystitis in an immunocompetent individual initially thought to be an orbital malignancy until the histopathological examination.

Cat-scratch disease masquerading as post-transplant lymphoproliferative disorder

Abstract Lymphadenopathy in an immunosuppressed patient raises the quintessential diagnostic dilemma: infection or malignancy? We present the case of a transplant recipient on anti-rejection prophylaxis admitted with acute fever, malaise and a swollen right axillary node. The patient had pancytopenia and tested positive for Epstein–Barr virus; nodal core biopsy demonstrated atypical plasma cell infiltration, immediately raising suspicion for post-transplant lymphoproliferative disorder. However, excisional biopsy and Bartonella henselae serology clarified a final diagnosis of cat-scratch disease—a potentially fatal zoonosis requiring a disparate treatment regimen. Here, we explore this patient’s investigations, hospital course and recovery, with an emphasis on recognizing and differentiating these diagnostic mimics in post-transplant practice.

Variable presentations of dengue fever with diagnostic dilemma: A case series

Dengue is a viral fever in humans which is caused by 4 serotypes of the flavivirus. It is spread by the bite of the infected Aedes mosquitoes. The acute febrile illness is often associated with multisystem involvement with complications. The case series presented here depicts atypical manifestations of dengue which may present with hypoplastic anemia, hepatitis, pancreatitis, and encephalopathy. The cases were diagnosed based on history of dengue with subsequent persistence of pancytopenia, presence of hepatitis, pancreatitis, and encephalopathy with serological evidence of dengue and after ruling out other possible etiologies supported by laboratory evidence of investigations. The bone marrow revealed pancytopenia with hypocellular marrow causing hypoplastic anemia, transaminitis and rise of lipase and amylase with symptoms diagnosed hepatitis, pancreatitis, and finally impairment of consciousness with electroencephalogram proved encephalopathy. The importance of the case series lies in the fact that atypical manifestations may occur in dengue patients challenging the physicians and early detection may avoid unnecessary treatment and complications.

Rare Extrapulmonary Tuberculosis: Covert symptoms and Diagnostic Dilemma.

Pulmonary tuberculosis may result in haematogenous and lymphatic extension in case of failure of early detection, or immunocompromised status, leading to extrapulmonary tuberculosis. Rare sites of extrapulmonary tuberculosis include the gastrointestinal tract, musculoskeletal system, genital tract, middle ear and pericardium. Histopathological findings of macro-confluent granuloma with or without caseous necrosis, along with detection of acid-fast bacilli (AFB) on Ziehl-Neelsen (ZN) staining, and GeneXpert for detection of Mycobacterium tuberculosis DNA, are key in establishing a diagnosis of tuberculosis. Biopsy-proven extrapulmonary granulomatous lesions were included in this study. Histopathological evaluation of all extrapulmonary biopsy specimens sent to the Department of Pathology were done for the presence of granuloma and necrosis, and ZN staining for AFB was done in all the cases of granulomatous lesions with or without the presence of necrosis. The same cases, with biopsy specimens sent in normal saline, were re-evaluated in a molecular laboratory with the help of GeneXpert MTB to detect the DNA of Mycobacterium tuberculosis. All biopsy specimens from extrapulmonary sites which were sent to the Department of Pathology were used for DNA extraction. Out of the 10 cases of extrapulmonary granulomatous lesions, 8 showed caseous necrosis on microscopy, and 7 showed the presence of acid-fast bacilli on Ziehl-Neelsen staining. GeneXpert detected DNA of Mycobacterium tuberculosis in 9 cases. Extrapulmonary tuberculosis rarely occurs as primary, and mostly spreads from lung parenchyma via a haematogenous route. Tuberculosis of the gastrointestinal tract, peritoneum, lymph nodes, and solid viscera are together termed abdominal tuberculosis. Entities like tuberculosis of the pericardium and ear are extremely rare. Extrapulmonary tuberculosis should be a differential in cases of chronic non-responding cases with diagnostic dilemmas. To avoid diagnostic delay, in cases of high suspicion, one should go for biopsy along with ZN staining for diagnostic confirmation as this is cost-effective, followed by GeneXpert for Mycobacterium tuberculosis in highly suspected cases with absent caseous necrosis and negative ZN staining.

Dirofilariasis Causing Pediatric Acute Scrotum: A Case Series and Review of the Literature.

Dirofilarial infestation has been reported as an extremely rare cause of pediatric acute scrotum. We aimed to evaluate clinical, radiological, and intraoperative findings of children who underwent surgical management for acute scrotum due to dirofilariasis in an endemic country. A retrospective study of patient records of children who underwent surgery for acute scrotum due to dirofilariasis between 2018 and 2022. There were eight emergency presentations for acute scrotum due to dirofilariasis. Three presentations (37.5%) were not associated with scrotal pain. The median age at presentation was 59 (range: 19-100) months. Four patients (67.7%) underwent emergency scrotal exploration at the first presentation and another one during the second presentation. Recurrent episodes were seen in two patients who were initially managed nonsurgically with antibiotics alone. Ultrasonography was performed in all six patients and revealed a parasitic nodule in three (50%). Dirofilariasis causing acute scrotum may cause significant diagnostic dilemma for clinicians. It may resemble idiopathic scrotal edema since it predominantly affects boys under 6 years of age and is painless in a significant proportion. However, left unoperated, it appears to have a high recurrence rate.

Blastomycosis: Report of a case from North India and its current status in the Indian subcontinent

Blastomycosis is a rarely known disease in India. This review traces the misdiagnosed cases of the disease reported as early as 1925 and later till 1997. Of the several authentic cases reported from India, only two have been authentically diagnosed autochthonous cases. Our case diagnosed on histological basis had a diagnostic dilemma as one of the PAS stained tissue section from the lesion showed slightly elongated yeast cells though these were with multiple budding. With the help of academic colleagues (joint authors in the paper), diagnosis of this case as blastomycosis was confirmed by latest molecular techniques as described in the case report. The clinical and diagnostic features of human autochthonous cases are reviewed. There is only known report of canine blastomycosis from India. It is suggested additional canine cases should be looked for in different parts of India to facilitate detection of endemic foci of B. dermatitidis in the country.

Parapharyngeal Abscess: A Model of Continuity and Contiguity Deep-Neck Space Infections: A Diagnostic Dilemma!

The aims of the present case report were to review, computed tomography (CT) scans, clinical signs, treatment, and outcome of parapharyngeal space infections. These infections remain an important health problem with significant risks of morbidity and mortality. The term parapharyngeal abscess or infection is composed of two different disorders: infection located in the posterior part of the PPS with no invasion into the parapharyngeal fat and the second disorder is when the infection involving the parapharyngeal fat may be termed parapharyngeal abscess or deep neck abscess. Diffusion into the mediastinum and other severe complications are frequent. A 59 year old male, presented with three days history of intermittent high grade fever and left neck swelling which was rapidly increasing in size and associated with stridor, odynophagia and neck pain. The infection and accumulation of purulent discharge extend into the pharyngomaxillary space and inferiorly is located at the greater cornu of the hyoid bone. Temporary tracheostomy for respiratory assistance was performed. The frequent co-existence of parapharyngeal abscess and peritonsillar abscess favours careful consideration of addition of tracheotomy to lateral cervicotomy. Parapharyngeal abscess are deep neck abscesses that are common and thorough knowledge of their complex anatomy and aetiologies is essential in their treatment. Urgent surgical drainage is therefore mandatory.

Prenatal diagnosis of fetal neurogenic megacystis associated with lethal congenital contractural syndrome 2

Abstract Objectives To describe the prenatal diagnosis, unique clinical features, clinical and genetic evaluation, and the pregnancy and neonatal course of two siblings affected by Lethal Congenital Contractural Syndrome 2 (LCCS2). Case presentation We present two cases of LCCS2, a rare autosomal recessive disorder in the arthrogryposis multiplex spectrum of syndromes whose sine qua non feature is the presence of nonobstructive, neurogenic megacystis. The prenatal diagnosis of this syndrome has not been previously reported. This syndrome has been previously studied in detail in an Israeli-Bedouin kindred but it has not been reported in the Americas. Conclusions These two cases illustrate the diagnostic and therapeutic dilemmas associated with this rare genetic abnormality. LCCS2 can be seen in other patient populations besides Israeli-Bedouin. They also suggest the presence of phenotypic variability in the clinical outcomes. Finally, they underscore the need for specialized diagnostic capabilities, the involvement of multidisciplinary teams to support challenging family situations, and the need for shared decision-making.

Clinical prediction model: Multisystem inflammatory syndrome in children versus Kawasaki disease.

Multisystem inflammatory syndrome in children (MIS-C) is a rare but serious complication of severe acute respiratory syndrome coronavirus 2 infection. Features of MIS-C overlap with those of Kawasaki disease (KD). The study objective was to develop a prediction model to assist with this diagnostic dilemma. Data from a retrospective cohort of children hospitalized with KD before the coronavirus disease 2019 pandemic were compared to a prospective cohort of children hospitalized with MIS-C. A bootstrapped backwards selection process was used to develop a logistic regression model predicting the probability of MIS-C diagnosis. A nomogram was created for application to individual patients. Compared to children with incomplete and complete KD (N = 602), children with MIS-C (N = 105) were older and had longer hospitalizations; more frequent intensive care unit admissions and vasopressor use; lower white blood cell count, lymphocyte count, erythrocyte sedimentation rate, platelet count, sodium, and alanine aminotransferase; and higher hemoglobin and C-reactive protein (CRP) at admission. Left ventricular dysfunction was more frequent in patients with MIS-C, whereas coronary abnormalities were more common in those with KD. The final prediction model included age, sodium, platelet count, alanine aminotransferase, reduction in left ventricular ejection fraction, and CRP. The model exhibited good discrimination with AUC 0.96 (95% confidence interval: [0.94-0.98]) and was well calibrated (optimism-corrected intercept of -0.020 and slope of 0.99). A diagnostic prediction model utilizing admission information provides excellent discrimination between MIS-C and KD. This model may be useful for diagnosis of MIS-C but requires external validation.

Revisiting the Malignant Masquerade at the Liver Hilum: Have We Made Progress?

Distinguishing malignant from benign causes of obstruction at the liver hilum can pose a diagnostic dilemma. This study aimed to determine factors that predict benign causes of hilar obstruction and long-term outcomes after resection. Consecutive patients who underwent surgery for hilar obstruction at a single institution between 1997 and 2022 were retrospectively analyzed. Median follow-up was 26months (range 0-281months). Among 182 patients who underwent surgery for hilar obstruction, 25 (14%) patients were found to have benign disease. Median CA19-9 level after normalization of serum bilirubin was 80U/mL (range 1-5779) and 21U/mL (range 1-681) among patients with malignant and benign strictures, respectively (p = 0.001). Cross-sectional imaging features associated with malignancy were lobar atrophy, soft tissue mass/infiltration, and vascular involvement (all p < 0.05). Factors not correlated with malignancy were jaundice upon presentation, peak serum bilirubin, sex, and race. Preoperative bile duct brushing or biopsy had sensitivity and specificity rates of 82% and 55%, respectively. Among patients who underwent resection with curative intent, grade 3-4 complications occurred in 55% and 29% of patients with malignant and benign strictures, respectively (p = 0.028). Postoperative long-term complications of chronic portal hypertension and recurrent cholangitis occurred in ≥ 10% of patients with both benign and malignant disease (p = non-significant). Strictures at the liver hilum continue to present diagnostic and management challenges. Postoperative complications and long-term sequelae of portal hypertension and recurrent cholangitis develop in a significant number of patients after resection of both benign and malignant strictures.

P476 Correlation between fecal calprotectin and inflammation on ultrasound in fibrostenotic Crohn’s Disease

Abstract Background Fibrostenotic Crohn’s Disease (CD) is a challenging phenotype particularly due to the absence of intestinal anti-fibrotic therapies. Differentiating between strictures that are predominantly fibrotic versus inflammatory remains a diagnostic dilemma. The ability to make this differentiation is critical to inform therapeutic decisions. Fecal calprotectin (FC) is a stool marker reflective of intestinal inflammation. Very few studies have evaluated the relationship of FC concentration in ileal CD strictures and parameters of inflammation on intestinal ultrasound (IUS). Strictures on imaging are defined as 1) increased bowel wall thickness (BWT), 2) narrowed luminal apposition, and 3) pre-stenotic dilation (PSD). BWT and hyperemia (color Doppler signal (CDS)) are the most sensitive markers for CD inflammation on IUS. It is predicted that FC will match CDS in ileal strictures, similar to non-stricture phenotypes. We aim to correlate FC levels with IUS inflammation of ileal CD strictures. Methods We performed a retrospective cohort pilot study exploring the relationship between FC levels and IUS inflammatory parameters in ileal strictures. FC levels were obtained ≤ 60 days of index IUS in fibrostenotic ileal CD patients. Individuals who underwent medication changes or experienced a clinical flare during this period were excluded. Inflammation was measured as BWT and CDS using a modified Limberg (ML) score. Pearson correlation for continuous variables, Spearman rank correlation and a Kruskal-Wallis test for FC and Limberg scale were completed. Results A total of 25 fecal samples were obtained from 17 patients with ileal strictures (47% male, median age 59 years (range 18-76)) were assessed. Median FC concentrations was 204.9 ug/g, IQR: 250.4. Median ileal stricture BWT was 7.0 mm (range 3.0–10.0). 40% (10/25) had ML1 (short chains in bowel), 32% (8/25) ML2 (long chains in bowel), and 28% (7/25) ML3 (long chains and perienteric fat). There was no correlation between FC and BWT (r=0.02, p=0.92), nor FC with ML scores (r=0.20, p=0.25). In those with ML1, median FC was 232.4, while those with ML2 or 3, had a FC of 155.6 and 469.7, respectively. FC values were significantly different between the ML scores, p&amp;lt;0.0001. Conclusion FC levels were not correlated with inflammatory parameters as seen on IUS in ileal CD. This unexpected finding may be due to ML2 scores having lower FC than anticipated, and small sample size. Other imaging factors such as loss of wall stratification need to be taken into account, and are perhaps more reflective of inflammation than BWT and CDS. This study provides the initial data to assess accuracy of FC and hyperemia of ileal CD strictures on IUS compared to histologic measures of inflammation on resected specimens.

Giant Dental Calculus Mimicking a Tumor: A Case Report

Dental calculus consists of mineralized bacterial plaque that forms on the surfaces of natural teeth and dental prostheses. Giant dental calculus mimicking a tumor is an unusual presentation. Buccal surfaces of the maxillary molars and the lingual surfaces of the mandibular anterior teeth are the most common location for calculus deposition. This case report presents a case of giant dental calculus mimicking a tumor on the labial surface of the mandible and its diagnostic dilemma, treatment and role of proper oral hygiene measures.

A giant hemorrhagic adrenal pseudocyst as a cause of a diagnostic dilemma.

A giant hemorrhagic adrenal pseudocyst as a cause of a diagnostic dilemma.