Gastrointestinal Tract Involvement Research Articles

The Impact of COVID-19 in Gastroenterology and Hepatology.

The 2019 coronavirus disease (COVID-19), an airborne infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in a global pandemic. SARS-CoV-2 relies on the angiotensin-converting enzyme 2 receptor for cellular entry and the abundance of this receptor in the gastrointestinal (GI) tract may help explain the GI manifestations, including dysgeusia, nausea, vomiting, diarrhea, and abdominal pain, present in over 40% of infected patients. GI tract involvement also raises the concern for oral-fecal transmission which is poorly understood. Outcome studies in COVID-19 patients with preexisting liver disease and inflammatory bowel disease show predominantly mild transaminase elevations and no increased risk from the use of biological agents in inflammatory bowel disease patients. High-dose corticosteroids, however, should be avoided. As endoscopic procedures are aerosol-generating, modifications to clinical practice is necessary to minimize the spread of COVID-19. We have reviewed current literature to describe the impact of COVID-19 in gastroenterology and hepatology as well as targets of future research.

Mucormycosis-unusual cause of lower GI bleeding: A rare case report.

IntroductionMucormycosis is a rare systemic fungal infection seen in immune-compromised patients. Gastrointestinal tract involvement is not usual.Case presentationA 36 years female presented with fever and progressive bilateral leg swelling for 25 days. She was diagnosed as nephrotic syndrome and started on methylprednisolone and cyclophosphamide. She developed hematochezia during hospital stay. On colonoscopy, ulcero-proliferative lesion was noted in caecum. Histopathology examination has confirmed it as mucormycosis of Caecum.DiscussionMucormycosis is an opportunistic angioinvasive disease caused by fungus zygomycosis it is a rare disease and often manifests as a life-threatening condition in immune-compromised patient. Invasion by fungal hyphae leads to arterial thrombosis, tissue infarction, hemorrhage and, necrosis. Diagnosis is confirmed by histopathological examination and culture. It is usually treated by the anti-fungal drug- liposomal amphotericin and surgical debridement.ConclusionMucormycosis is a fatal systemic fungal infection, which can present as lower gastrointestinal bleeding in immunocompromised patients.

Gastrointestinal bleeding with Klippel\u2013Trenaunay syndrome: a case report

BackgroundGastrointestinal bleeding caused by gastrointestinal tract involvement in patients with Klippel–Trenaunay syndrome (KTS) is extremely rare and often overlooked.Case presentationA 9-year-old girl who presented with chronic gastrointestinal bleeding was admitted to our hospital. Laboratory examinations revealed microcytic hypochromic anemia and a positive fecal occult blood test. Computed tomography (CT) of the lower limbs combined with physical examination confirmed KTS. The pelvic CT showed concentric thickening of the sigmoid colon and rectum, with progressive enhancement after the administration of a contrast agent. Colonoscopy demonstrated vascular malformations of the sigmoid colon and rectum. The patient was finally diagnosed with KTS with gastrointestinal tract involvement. The patient improved after receiving conservative treatment.ConclusionsA suspicion of gastrointestinal tract involvement as an etiology for gastrointestinal bleeding should not be overlooked in patients with KTS. Endoscopy and imaging modalities can synergistically help diagnose this condition.

Immunosuppression does not prevent severe gastrointestinal tract involvement in systemic sclerosis.

We aimed to test the hypothesis that exposure to immunosuppression in early systemic sclerosis (SSc) could modify the risk of developing new onset severe gastrointestinal (GIT) involvement. A total of 762 subjects with <3 years of disease duration and without severe GIT disease at baseline study visit were identified from combined longitudinal cohort data from the Canadian Scleroderma Research Group (CSRG) and Australian Scleroderma Interest Group (ASIG). The primary exposure was ever use of methotrexate, cyclophosphamide, mycophenolate mofetil and/or azathioprine during the study period. Severe GIT disease was defined as: 1-malabsorption, 2-hyperalimentation, 3-pseudo-obstruction, and/or 4-≥10% weight loss in association with the use of antibiotics for bacterial overgrowth or oesophageal stricture. The change in the hazard of severe GIT disease due to exposure was estimated using a marginal structural Cox proportional hazards model fit by inverse probability of treatment weights (IPTW) to address potential confounding. Study subjects were 81.5% female, had a mean age of 53.7±13.0 years and mean disease duration at baseline of 1.4±0.8 years. During a mean follow-up of 4.0±2.6 years, severe GIT involvement developed in 11.6% of the 319 subjects exposed to immunosuppression and in 6.8% of the 443 unexposed subjects. In an IPTW-adjusted analysis, exposure to immunosuppression was not associated with severe GIT disease (weighted hazard ratio 0.91, 95% confidence interval 0.52-1.58). In this large inception SSc cohort, the risk of severe GIT involvement was not modified by exposure to immunosuppression.

Acute mesenteric ischemia and small bowel imaging findings in COVID-19: A comprehensive review of the literature

BACKGROUNDCoronavirus disease 2019 (COVID-19), an infectious condition caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has rapidly spread worldwide since its first description in Wuhan in December 2019. Even though respiratory manifestations are the most prevalent and responsible for disease morbidity and mortality, extrapulmonary involvement has progressively gained relevance. In particular, gastrointestinal (GI) signs and symptoms, reported in up to two-thirds of patients with COVID-19, might represent the first and, in some cases, the only disease presentation. Their presence has been associated in some studies with an increased risk of a severe disease course. Proposed pathogenic mechanisms explaining GI tract involvement are either direct viral access to intestinal cells via angiotensin-converting enzyme 2 or indirect damage of the intestinal wall through mesenteric ischemia induced by the hypercoagulable state associated with COVID-19 infection. Although not typical of SARS-CoV-2 infection, several small bowel manifestations have been described in infected patients who underwent any form of abdominal imaging. The radiological findings were mainly reported in patients with abdominal symptoms, among which abdominal pain was the most common.AIMTo discuss small bowel radiological manifestations of SARS-CoV-2 infection in abdominal imaging studies.METHODSBibliographical searches were performed in PubMed, using the following keywords: “COVID-19” AND “imaging” AND “gastrointestinal” OR “abdominal” OR “small bowel”.RESULTSOf 62 patients with described radiologic small bowel alterations, mesenteric ischemia was diagnosed in 31 cases (50%), small bowel wall thickening in 10 cases (16%), pneumatosis in nine cases (15%), intussusception in eight cases (13%), pneumoperitoneum in two cases (3%) and paralytic ileus in two cases (3%). We also reported mesenteric adipose tissue hypertrophy and lymph nodes enlargement in a young woman.CONCLUSIONSo far it is difficult to establish whether these manifestations are the direct consequence of SARS-CoV-2 infection or collateral findings in infected patients, but their recognition would be pivotal to set a closer follow-up and to reduce missed diagnoses.

Upper Gastrointestinal Tract Involvement in Inflammatory Bowel Diseases: Histologic Clues and Pitfalls.

The upper gastrointestinal (UGI) manifestations of inflammatory bowel diseases (IBDs) are frequently obscured by classic ileal and colonic symptoms and are reported to involve only 0.5% to 4% of adult patients. However, because of the improvement of endoscopic techniques and the growing use of esophagogastroduodenososcopy with biopsy, both asymptomatic and clinically significant esophageal, gastric, and duodenal manifestations are increasingly recognized. The UGI involvement in IBD was historically synonymous with Crohn’s disease (CD), but the doctrine of ulcerative colitis (UC) being limited to the colon has been challenged, and UC-related gastroduodenal lesions have been reported. The diagnosis of UGI IBD should ideally rely on a combination of the clinical history, endoscopic picture, and histologic features. Although endoscopic changes such as aphthoid or longitudinal ulcers and bamboo-joint-like pattern are suggestive of CD, histologic evaluation increases the sensitivity of the IBD diagnosis since histologic alterations may be present in endoscopically unremarkable mucosa. Conversely, in many cases, the histologic findings are nonspecific, and the knowledge of clinical history is vital for reaching an accurate diagnosis. The presence of epithelioid granuloma is highly suggestive of CD but is present in a minority of CD cases; thus, pathologists should be aware of how to diagnose UGI IBD in the absence of granulomata. This article reviews the most important clinical, endoscopic, and histologic features of IBD-associated esophagitis, gastritis, and duodenitis, as well as the IBD-related manifestations in the biliary tract and the postcolectomy setting.

Genital and Intertriginous Rashes Refractory to Antimicrobial Treatments: Have You Thought about Crohn’s Disease?

Crohn's disease is an inflammatory bowel disease that can have multiple extraintestinal manifestations and can develop prior to, following, or simultaneously with gastrointestinal tract involvement (Aberumand et al. (2017), Georgious et al. (2006), Larsen et al. (2010), Levine and Burakoff (2011), Louis et al. (2018)). This report examines the case of a 16-year-old male with a rash of the genital, intergluteal, and inguinal regions refractory to antimicrobial treatments suspicious for an extraintestinal manifestation of Crohn's disease. The patient was diagnosed with inflammatory, nonfistulizing colonic Crohn's disease following presentation with gastrointestinal symptoms including abdominal pain and bloody stools 6 months after the onset of the rash. The genital lesions resolved after starting treatment for Crohn's disease with adalimumab.

Clinical significance of anti-NOR90 antibodies in systemic sclerosis and idiopathic interstitial pneumonia.

Anti-NOR90 antibodies are usually found in patients with SSc; however, their clinical relevance remains obscure. We developed an ELISA for measuring them to investigate the clinical features of patients with anti-NOR90 antibodies. Serum samples from 1252 patients with various conditions from Nagoya University Hospital and 244 patients with idiopathic interstitial pneumonia (IIP) from Tosei General Hospital were included. Anti-NOR90 antibodies were assayed by an ELISA using the recombinant protein produced by in vitro transcription/translation. Five (0.4%) patients in the Nagoya University Hospital cohort had anti-NOR90 antibodies. One patient with diffuse cutaneous SSc, three with limited cutaneous SSc, and one with Raynaud's disease were positive for anti-NOR90 antibodies. Anti-NOR90 antibodies were found more frequently in patients with systemic scleroderma-spectrum disorders (SSDs) than without SSDs (5/316 vs 0/936, P <0.00101) and were found more frequently in patients with SSc than without SSc (4/249 vs 0/528, P <0.0104) in the systemic autoimmune rheumatic diseases cohort. Three of the four anti-NOR90-positive SSc patients had interstitial lung disease (ILD), and two of those four had cancer. Three (1.2%) patients in the Tosei General Hospital cohort had anti-NOR90 antibodies. All three of the anti-NOR90-positive IIP patients had gastrointestinal tract involvement, and two of those three had cancer or skin lesions observed in SSc. Although anti-NOR90 antibodies are rarely found in clinics, our ELISA is useful for their detection. Further studies are needed to confirm the association of anti-NOR90 antibodies with ILD and cancer in SSc and IIP patients.

Acute Ischemic Stroke- A presenting feature of SARS-CoV-2 infection

The ongoing pandemic caused by coronavirus disease (COVID-19) is now a global concern. Although SARS-CoV-2 primarily involves lung, there are emerging data on involvement of heart, brain, kidney, gastrointestinal tract, liver and others. Amongst neurological manifestations, acute stroke, encephalitis and GBS are reported. Here we describe two RT-PCR confirmed SARS-CoV-2 infected patients presented with acute ischemic stroke. The possible background mechanisms are arterial thrombosis due to hypercoagulability, direct and immune-mediated neuronal damage, viral vasculopathy, cardio-embolism etc. BSMMU J 2021; 14 (COVID -19 Supplement): 60-63

Hepatobiliary and Gastrointestinal Involvement in Langerhans Cell Histiocytosis-Spectrum of Three Cases.

Langerhans cell histiocytosis (LCH) is a rare group of disorder, due to clonal neoplastic proliferation of dendritic cells in the bone marrow expressing a Langerhans cell phenotype. 1 This disease particularly affects the pediatric age group and young adults and often presents with skin rashes, lung infiltrates, and bone lesions. It can also manifest with endocrine dysfunction and hematopoietic disorders. Involvement of gastrointestinal tract is very rare. Herein, we present a spectrum of three cases with gastrointestinal involvement.

Prognostic Impact of Extranodal Involvement in Newly Diagnosed Diffuse Large B-Cell Lymphoma

Introduction: Involvement of >1 extranodal site is regarded as a poor prognostic factor for patients with diffuse large B-cell lymphoma (DLBCL). It is necessary to clarify the prognostic impact of specific extranodal sites.Methods: Patients with newly diagnosed DLBCL treated at the University of Heidelberg between 06/2001 and 07/2015 were identified and included in this retrospective analysis. Data on clinical characteristics and treatment modalities were obtained by review of medical charts. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method. The impact of variables on PFS and OS was evaluated by univariate log-rank tests and by multivariate analysis using the Cox proportional hazards model.Results: A total of 1001 patients were identified of whom 646 (65.1%) presented with extranodal involvement. Median age was 64.6 years [range 18.6-92.5], 540 (53.9%) were male. 820 patients had an available international prognostic index (IPI) score, 295 (36%) IPI 0-1, 398 (48.5%) IPI 2-3, and 127 (15.5%) IPI 4-5. The most frequently involved extranodal sites were central nervous system (CNS) (15.3%), soft tissue (14.4%), gastrointestinal tract (11.9%), bone (11.1%), lungs/pleura (9.7%), liver (6.2%), kidney (3.3%), pancreas (2.6%), and testis (2.5%).878 patients were treated in curative intent and were further analyzed regarding the prognostic impact of extranodal involvement on outcome. 69.7% of them received CHOP-like therapies, 28.9% received chemotherapy more aggressive than CHOP, typically addition of etoposide or treatment with high-dose methotrexate in case of CNS involvement, 86.4% received additional rituximab, and 24% additional radiotherapy.All involvement sites were evaluated by univariate analysis for OS. Sites associated with decreased OS (P <.05) were CNS, lungs/pleura, liver, kidney, malignant ascites and pharynx. Multivariate Cox Regression analysis of the 20 most common involvement sites revealed that patients with involvement of CNS, lungs and/or pleura, liver, kidney, and pharynx had significantly worse OS (P <.05).We identified three involvement sites that had worse PFS by univariate analysis: CNS, lungs/pleura, and kidney. Multivariate Cox Regression analysis revealed that patients with involvement of CNS, lung and pleura, bone marrow, and kidney had significantly worse PFS (P <.05). On the contrary, involvement of the salivary glands was significantly associated with higher PFS in multivariate analysis (P=.044).The involvement of gastrointestinal tract (n=107) did not have any significant prognostic impact related to OS or PFS.Conclusions: In this retrospective registry analysis of patients with newly diagnosed DLBCL, involvement of CNS, lungs/pleura, and kidney were identified as risk factors for both inferior PFS and OS. In contrast, involvement of salivary glands was related with better PFS. Further analyses are required as toward which treatment modalities might be best suited to overcome the inferior prognosis of some extranodal involvements and to avoid the overtreatment of other involvements. DisclosuresKriegsmann:BMS: Research Funding; Celgene: Research Funding.

Mantle Cell Lymphoma Mimicking Mucosa-Associated Lymphoid Tissue (MALT) Lymphomas: A Pathological Characterization (on behalf of the “Fondazione Italiana Linfomi (FIL) - Postgraduate Master Course”)

INTRODUCTION: Mantle Cell Lymphoma (MCL) is considered an aggressive B-cell lymphoma, but with a heterogeneous outcome and a median overall survival ranging from 3 to 5 years (yrs). Two different subsets are recognized, known as “classical” and “leukemic non-nodal” subtypes. Unfrequently MCL presents with isolated extranodal localization mimicking mucosa-associated lymphoid tissue (MALT) lymphomas; a large series of European Mantle Cell Network has been recently reported (Morello et al, ICML 2017). On the other side, pathological features of this peculiar presentation are not yet clarified.METHODS: We collected data on 34 patients (pts) with extranodal mantle cell lymphoma (EMCL) of MALT site, diagnosed between 2001 and 2016 in 10 Italian Centers of Fondazione Italiana Linfomi (FIL) network. The diagnosis of MCL was confirmed through detection of CyclinD1 overexpression and/or t(11;14). All pts were >18 yrs and HIV negative. Only minimal locoregional nodal involvement, with CT longest axis <2 cm, and bone marrow involvement with only extranodal disease were allowed. Pts with splenomegaly and leukemic disease were excluded. We performed a central pathological review of 21/34 cases (62%) in the Section of Anatomic Pathology of University of Pavia and compared their features with a cohort of nodal MCL.RESULTS: Clinical features and treatments are summarised in Table 1.Biopsied extranodal sites were as follows: 11 pts (32%) Waldeyer's ring, 11 (32%) gastrointestinal tract, 3 (9%) ocular adnexa, 3 (9%) oral cavity, 3 (9%) salivary glands, 2 (6%) thyroid and 1 (3%) liver. Detailed morphology was assessed in 28 pts: classical in 22 pts (78%), pleomorphic in 3 (11%) and blastoid in 3 (11%). CD5 expression was performed in 31 cases: 21 (68%) positive, 6 (19%) partially positive and 4 (13%) negative. Median Mib1/Ki67 was low (15%, range: 2-70%), <30% in 83% and ≥30% in 17% cases. CyclinD1 was available in 33 pts (88% positive, 3% negative, 9% partially positive) and t(11:14) in 13 pts (92% positive). SOX11 staining was performed in 21 cases: 17 (81%) resulted positive, 3 (14%) partially positive and only 1 (5%) negative. Overall, no statistically significant difference with nodal MCL series was observed, particularly regarding cytological features, CD5 and SOX11 expression and Mib1/Ki67. MIPI score was calculated in 33 pts: 15 (46%) low, 13 (39%) intermediate and 5 (15%) high; biologic-MIPI score was available in 29 pts: 7 (24%) low, 14 (48%) intermediate and 8 (28%) high.After a median follow-up of 5.1 yrs (0.5-15), overall survival (OS) was 93% at 5 yrs and 75% at 10 yrs with 4 deaths (2 for lymphoma, 2 for unknown cause). All the 12 pts treated with autologous stem cell transplantation was still alive at last follow-up. Progression-free survival (PFS) was 74% after 5 yrs and 64% after 10 yrs of follow-up. Univariate analysis results are overlapping with European series: pts with age <65 yrs (p=0.002), ECOG 0 (p=0.012), low MIPI score (p=0.005) and low biologic MIPI score (p=0.008) had a longer OS. In univariate analysis, a longer PFS was observed in pts with age <65 yrs (p=0.016), ECOG 0 (p=0.002), low MIPI score (p<0.001) and low biologic MIPI score (p=0.011). In multivariate analysis, age (p=0.022) confirmed its impact on PFS, after adjusting for biologic MIPI score.CONCLUSIONS: According to our preliminary data, we define EMCL as a subset with preferential involvement of Waldeyer's ring and gastrointestinal tract, mimicking the clinic-pathologic features of marginal zone lymphoma of extranodal sites, from which it should be differentiated via a thorough histologic characterization, and featuring the indolent course of the indolent variant of MCL. On the other hand, our cases harbored the morphologic and phenotypic features of the nodal form of MCL. On the basis, the true nature of this putative MCL subset should be deepened upon biologic characterization, including mutational and IGVH status analysis. [Display omitted] DisclosuresLoseto:gilead: Membership on an entity's Board of Directors or advisory committees; janssen: Consultancy; italfarmaco: Membership on an entity's Board of Directors or advisory committees. Arcaini:Pfizer: Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees; Bayer: Membership on an entity's Board of Directors or advisory committees; Roche: Consultancy, Membership on an entity's Board of Directors or advisory committees; Sandoz: Consultancy; Gilead: Research Funding. Zaja:Novartis: Honoraria, Research Funding; Roche: Honoraria, Research Funding; Abbvie: Honoraria; Takeda: Honoraria; Gilead: Honoraria; Janssem: Honoraria; Celgene: Honoraria, Research Funding.

The Presence of Pleural Effusion at Diagnosis Predicts Poor Outcomes in Diffuse Large B-Cell Lymphoma Patients with MYC -Rearrangement or Double Protein Expression

Background: Diffuse large B-cell lymphomas (DLBCLs) with MYC -rearrangement (MYC -R) or double protein expression (DE) of the MYC and BCL2 are associated with poor prognosis. MYC -R reportedly occurs in approximately 5-14% of DLBCL cases. While the pathological and genetic prognostic factors for DLBCL with MYC -R have been reported, the clinical prognostic factors, including the extranodal sites involved, have not been fully elucidated. In the updated National Comprehensive Cancer Network guidelines for non-Hodgkin lymphomas, the presence of pleural effusion is a poor prognostic criterion for low-grade B-cell lymphomas; however, its prognostic significance in high-grade B-cell lymphomas is unclear. Therefore, we aimed to investigate the association between the presence of pleural effusion at diagnosis and outcomes in DLBCL with MYC -R or DE.Methods: To explore the prognostic significance of pleural effusion in high-grade B-cell lymphoma, we assessed the medical records of DLBCL patients with MYC -R or DE, treated at the Juntendo University Hospital and Juntendo University Urayasu Hospital from December 2009 to June 2017. A total of 84 patients, including 40 with MYC -R and 44 with DE, were assessed. All patients were treated with R-CHOP-based regimens, with minor modifications. Rearrangements of MYC, BCL2, and BCL6 were detected using fluorescence in situ hybridization. The presence of pleural effusion at diagnosis was evaluated by using radiographic evidence from computed tomography and/or positron emission tomography-computed tomography. This study was approved by the Institutional Review Board of Juntendo University Hospital. We analyzed the relationships of overall survival (OS) and progression-free survival (PFS) with age, sex, lactate dehydrogenase (LDH) level, Eastern Cooperative Oncology Group performance status (PS), stage, the presence of ≥2 extranodal sites, pleural effusion, and bone marrow, peripheral blood, bone, gastrointestinal tract, lung, paranasal sinus, and skin involvement. Univariate and multivariate analyses of the estimated risk factors for OS and PFS were performed using the log-rank test and Cox proportional hazard regression analysis, respectively.Results: The median age of the patients was 73 years (range: 39-92 years), 75% of the patients were older than 60 years, and 54.8% were male. Elevated LDH levels, PS ≥2, advanced stage disease, and ≥2 extranodal sites were found in 73.8%, 10.7%, 65.5%, and 25% of patients, respectively (Table 1). At diagnosis, pleural effusion was observed in 13 patients (15.5%; MYC -R: nine cases, DE: four cases). The presence of lymphoma-associated pleural effusion was confirmed on cytological evaluation in seven of these cases. The median OS and PFS was 14.5 (range: 1-87) and 13 (range: 0-87) months, respectively. Patients with pleural effusion at diagnosis had significantly shorter OS and PFS than those without pleural effusion (median OS: 8 months vs 18 months, P<0.001; median PFS: 4 months vs 15 months, P<0.001, Figure1 and 2). The multivariate analysis showed that pleural effusion (hazard ratio [HR] 3.2, 95% confidence interval [CI] 1.2-8.1, P=0.015) and bone marrow involvement (HR 3.1, 95% CI 1.2-7.7, P=0.015) were significantly associated with inferior OS. Pleural effusion (HR 4.3, 95% CI 1.6-12.1, P=0.0050) and PS ≥2 (HR 3.2, 95% CI 1.2-8.8, P=0.022) were significantly associated with inferior PFS.Conclusions: The presence of pleural effusion at diagnosis was independently associated with inferior OS and PFS in DLBCL with MYC -R or DE. These results may significantly influence the clinical management of DLBCL patients with MYC -R or DE. Because the presence of pleural effusion at diagnosis is a high-risk factor, it should be routinely evaluated, especially in patients with high-grade B-cell lymphoma. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Outcomes of CD19 Chimeric Antigen Receptor T Cell Therapy in Patients with Gastrointestinal Tract Involvement of Large B Cell Lymphoma

CD19-directed chimeric antigen receptor (CAR) T cell therapy with axicabtagene ciloleucel (axi-cel) or tisagenlecleucel (tisa-cel) is approved for the standard of care treatment of relapsed or refractory large B cell lymphoma (LBCL). Patients with LBCL involving the gastrointestinal (GI) tract are at risk of perforation after lymphoma-directed therapy. The outcomes of CAR T cell therapy in patients with GI involvement have not been reported previously. This study aimed to determine the safety and efficacy of CD19 CAR T cell therapy in patients with LBCL involvement of the GI tract. This was a single-center retrospective study of 130 consecutive patients treated with standard of care or expanded-access axi-cel or tisa-cel for LBCL. Twenty-four of these patients had radiologic involvement of the GI tract before CAR T infusion. Incidence rates of severe immune effector cell-mediated toxicities and clinical outcomes were compared between the GI involvement and non-GI involvement groups. Three of the 24 patients with GI tract involvement experienced perforation. One patient had a contained gastric perforation after leukapheresis while receiving bridging radiation therapy to the stomach. This patient was eventually able to proceed with lymphodepletion and product infusion. In the other 2 patients, GI tract perforation occurred at day +13 and day +35 after CAR T infusion. All 3 patients subsequently died while experiencing lymphoma progression. Upper GI bleeding occurred in 1 other patient in the context of progressive disease at 6 months after product infusion. The incidence rates of severe cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome, length of hospital stay, and use of anti-IL-6 and steroids were similar in the 24 patients with GI tract involvement and the 106 patients without GI tract involvement. No significant between-group differences were seen in the best overall response rate, progression-free survival, or overall survival. Our data show that outcomes of patients with GI tract involvement before CAR T cell therapy are similar to those without GI involvement, and that durable remissions can be observed. However, patients with preexisting GI tract involvement are at risk of perforation from disease progression before and after CAR T cell infusion.

A rare case of peripheral T cell lymphoma, not otherwise specified with cutaneous involvement and diffuse systemic metastasis

&lt;p class="abstract"&gt;Peripheral T-cell lymphoma (PTCL), a subdivision of T-cell non-Hodgkin lymphomas (NHLs), is rare and different from the more common cutaneous T-cell lymphomas. PTCL is a diverse group of disorders and carries a poor prognosis. Peripheral T cell lymphoma not otherwise specified (PTCL-NOS) is the most common and aggressive disorder out of the group, which involves the lymph nodes followed by the skin, liver, and gastrointestinal tract. We hereby report a case of a 60 years old female who presented to us with complaints of multiple painful dark-coloured nodular lesions and indurated plaques over bilateral upper limbs, lower limbs and trunk, for 3 months. After detail laboratory investigations, histopathological and immunohistochemistry which was positive for CD30 antigen we confirmed the diagnosis as PTCL-NOS. Radiological imaging showed involvement of gastrointestinal tract, adrenal gland and vertebrae. After thorough workup the patient was started on palliative radiotherapy, unfortunately she succumbed to death. In conclusion, PTCL-NOS with CD30 positivity is rare and aggressive with a poor prognosis, it is important to identify such cases and work in conjugation with an oncologist for proper management.&lt;/p&gt;

Linaclotide for the treatment of refractory lower bowel manifestations of systemic sclerosis

BackgroundLower gastrointestinal (GI) tract involvement can affect up to 50% of systemic sclerosis (SSc) patients, and may result in malabsorption, pseudo-obstruction, hospitalization, and death. We report our experience with linaclotide, a selective agonist of guanylate cyclase C (GC-C), for SSc patients with refractory lower GI disease.MethodsWe performed an analysis of patients seen at the Johns Hopkins Scleroderma Center and identified patients prescribed linaclotide for refractory lower GI manifestations. Patients had clinical data collected in our longitudinal database. Linaclotide responders were on medication for at least 12 months with documented effectiveness by the treating physician.ResultsThirty-one patients with SSc were treated with linaclotide. At the time of linaclotide initiation, 23 of these patients (74%) were classified as having severe GI disease, as defined by recurrent pseudo-obstruction, malabsorption, and/or need for artificial nutrition (Medsger GI severity score ≥ 3). The majority of patients (90.3%; 28/31) had a treatment response, while only three patients (9.7%) reported ineffectiveness or intolerable side effects. Low-dose linaclotide (≤ 145 mcg daily) was used in 18 patients and was effective in 94%. High-dose therapy (> 145 mcg daily) was effective in 11 of 13 patients (85%). Common side effects were diarrhea, cramping, or bloating (11/31, 35%). Ineffectiveness, cost, and abdominal pain were complaints cited among those who discontinued therapy.ConclusionLinaclotide is a well-tolerated and efficacious pro-secretory and pro-motility agent that can be used to manage refractory lower GI manifestations in SSc. We found that low-dose linaclotide is an effective option and may be better tolerated, though a subset of patients may require high dose regimens.

COVID-19 and the gastrointestinal tract: source of infection or merely a target of the inflammatory process following SARS-CoV-2 infection?

Gastrointestinal (GI) symptoms have been described in a conspicuous percentage of coronavirus disease 2019 (COVID-19) patients. This clinical evidence is supported by the detection of viral RNA in stool, which also supports the hypothesis of a possible fecal-oral transmission route. The involvement of GI tract in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is corroborated by the theoretical assumption that angiotensin converting enzyme 2, which is a SARS-CoV-2 target receptor, is present along the GI tract. Studies have pointed out that gut dysbiosis may occur in COVID-19 patients, with a possible correlation with disease severity and with complications such as multisystem inflammatory syndrome in children. However, the question to be addressed is whether dysbiosis is a consequence or a contributing cause of SARS-CoV-2 infection. In such a scenario, pharmacological therapies aimed at decreasing GI permeability may be beneficial for COVID-19 patients. Considering the possibility of a fecal-oral transmission route, water and environmental sanitation play a crucial role for COVID-19 containment, especially in developing countries.

Incidental lymphomas in surgical pathology: diagnostic clues and clinical-pathological correlations.

Incidental lymphomas (ILs) are rare and challenging lesions with poorly characterized clinical-epidemiological and histological features. The present study addressed the open issues concerning these tumors, by assessing the clinical-pathological features of 28 consecutive ILs, diagnosed over a 10-year period at a tertiary center for surgical pathology. ILs were more frequently documented in elderly males (mean age at surgery 70.8 years; M/F ratio 3.3), with sharp prevalence of gastrointestinal and urinary tract involvement (22/28 [78.6%] cases). Low-grade B-cell lymphomas outnumbered all other entities, and chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) was the most common subtype (18/28 [64.3%] cases). Compared to other ILs, CLL/SLL occurred at older age and was the sole lymphoid neoplasm affecting the urinary tract. In conclusion, ILs are rare lesions, mostly affecting the gastrointestinal and urinary tract of elderly males. The diagnosis of IL is based on a high degree of suspicion and on careful morphological/phenotypic characterization.

POS-201 INFECTIOUS COLITIS DEVELOPING IN TWO PATIENTS NEWLY DIAGNOSED WITH MULTIPLE MYELOMA

Multiple myeloma , although a rare disease, is the second most common hematologic malignancy. Infections represent a major threat to multiple myeloma patients, being the greatest risk of early death and they commonly affect respiratory and urinary tract. Involvement of gastrointestinal tract has been rarely reported .We describe the case of two female patients admitted to our department for multiple myelome with renal impairment, and who developed infectious colitis during hospitalization. Our two patients had 63 and 57 years old respectively. In both cases, stage II mutiple myeloma has been recently diagnosed and combination chemotherapy (Velcade-Prednisolone –Thalidomide) was used for the treatment on admission. One week later, the first patient developed fever and a sub-occlusive syndrome while the second patient complained of nausea and bloody diarrhea with abdominal pain. Elevated CRP was noted in both cases. An abdominal computed tomography (CT) scan was performed in the first case showing diffuse edematous thickening of the colorectal wall, compatible with infectious colitis. Rectosigmoidoscopy revealed mucosal erythema with superficial erosions in both cases. Colonic biopsies showed acute infectious colitis with edema and neutrophil infiltration. No viral inclusion was noted. Stool culture isolated Escherichia coli in the second case. The two patients were treated with antibiotics inclunding Metronidazole and they both improved within a few days. Evidence of the coexistence of multiple myeloma and gastrointestinal tract involvement can be found in the literature and is thought to be a result of amyloid deposition. To our knowledge, there have been no previously reported cases of infectious colitis during myeloma. Such complication should be kept in mind and prompt diagnosis with appropriate anti-infective chemotherapy must be started in order to reduce the risk of mortality.

A rare presentation of gastric sarcoidosis

Abstract Introduction: Sarcoidosis is a multisystem inflammatory disease involving non-necrotizing epithelioid granulomas with an unknown etiology. Here we present a case of systemic sarcoidosis that involves the gastrointestinal tract. Patient concerns: A 45-year old Hispanic female initially presented with nonspecific symptoms including dysphagia and an unintentional weight loss of 65 lbs. Diagnosis: After extensive workup including endoscopy with biopsy, she was diagnosed with systemic sarcoidosis with gastrointestinal (GI), pulmonary and musculoskeletal involvement. Interventions: She was started on prednisone 60 mg daily and 15 mg of methotrexate subcutaneously with titration up to 22.5 mg. Outcomes: She has had significant improvement in symptoms. Currently her symptoms are well controlled on 22.5 mg of subcutaneous methotrexate weekly and folic acid 1 mg daily. She was seen by a pulmonologist who recommended monitoring with pulmonary function test and computed tomography chest every 6 months. Conclusion: In patients with known pulmonary sarcoidosis, nonspecific GI symptoms, and inconclusive tests, sarcoidosis with GI tract involvement should be considered.