Hematogenous Dissemination Research Articles

Systemic Candidosis in Dogs Associated with Canine Distemper Virus

Background: Candidosis is an opportunistic fungal infection caused by yeasts of the genus Candida, which normally reside on the surfaces of the mucous membranes and in the skin of several animal species and healthy humans; however the fungi can convert into pathogenic microorganisms and result in invasive infections with systemic involvement due to the impairment of the immune system. Systemic candidosis is rare in dogs and few reports of this mycosis are available in literature. Therefore, the objective of this study was to describe three cases of systemic candidiasis associated to canine distemper in dogs, highlighting the main epidemiological, clinical and pathological aspects.Cases: Three cases of systemic infection by Candida sp. were diagnosed in dogs. The animals predominantly presented neurological clinical manifestations, followed by unspecific alterations with an evolution of 5 to 30 days. Macroscopically, the lesions were characterized by white-yellowish multifocal to coalescent areas surrounded by reddish borders in the kidneys and heart (cases 1, 2 and 3); liver and submandibular lymph node (case 1); and lung (case 2). In the brains of the three dogs were observed multifocal, blackened and/or reddish and friable areas. In case 1, was observed an increased volume of the right carpometacarpal joint, that when cut, released a reddish and turbid content. In case 2, there was deposition of a whitish lumpy material on the epicardial surface, aorta artery, pericardial sac and spleen; infarction on the right testicle, hydroureter, pyelonephritis and hydronephrosis. Microscopically, the lesions consisted of necrossupurative inflammation associated to hemorrhage, vasculitis, congestion, thrombosis, infarction and fungal structures with distinct morphological patterns which included blastoconidia, pseudohyphae and hyphae. The fungal structures were strongly positive for the anti-Candida albicans polyclonal antibody in the immunohistochemistry. All 3 dogs were concomitantly infected by the canine distemper virus, and 2 of the animals also presented other comorbidities.Discussion: The diagnosis of systemic candidiasis was made based on the morphotintorial characteristics of the agent and confirmed by immunohistochemistry. The yeasts of the genus Candida live as commensals, but when there is an imbalance of the normal microbiota or the immune system of the host is impaired, the yeasts can convert themselves into opportunistic pathogenic microorganisms. The concomitant infection with the canine distemper virus may have favored the infection and proliferation of the agent in the tissues, as the virus causes immunosuppression. The extensive vascular lesions associated to fungi in the vascular lumen and wall observed in the affected organs suggest hematogenous dissemination causing acute infarctions. The clinical signs of systemic candidosis are extremely variable and reflect the affected organs and hardly ever the infections are considered in the differential diagnoses. The dogs presented neurological clinical signs compatible with canine distemper, however the other clinical alterations were unspecific and insufficient to correlate with a secondary infection and none of the cases diagnosed in the necroscopic examination suggested systemic candidiasis during the clinical investigation. The histochemical methods used in this study contributed effectively for the prior diagnosis of candidosis, making evident the variable morphological characteristics of the fungi. It is concluded that the systemic candidosis in dogs with canine distemper affects young and adult animals with predominantly neurological and unspecific clinical signs resulting from necrossupurative and vascular lesions in several organs, including the articular involvement little described in dogs and testicular lesions only reported in humans.

Molecular epidemiology of Aspergillus species and other moulds in respiratory samples from Argentinean patients with cystic fibrosis.

In cystic fibrosis (CF) patients, fungal colonization of the respiratory tract is frequently found. Aspergillus fumigatus is the most frequently recorded and is associated with loss of pulmonary function and allergic disease (ABPA). The knowledge on prevalence rates of filamentous fungi in CF patients in Latin America is scarce. One hundred and seventy-six fungal isolates recovered from the upper respiratory tract of CF patients from Argentina were identified to species by morphology and DNA sequencing. In total, 90% of CF patients were colonized by Aspergillus sp., followed by Exophiala sp. (14%) and Scedosporium sp. (10%). Among Aspergillus, six species complexes (Fumigati, Flavi, Terrei, Nigri, Usti, and Nidulante) and different cryptospecies were found. Among Scedosporium, three species were observed (Scedosporium apiospermum, Scedosporium aurantiacum and Scedosporium boydii). All Exophiala isolates were identified as Exophiala dermatitidis. Rare filamentous fungi were also found. All cases of ABPA were associated to the presence of A. fumigatus. Mixed colonization with other mould or rare fungi was observed in half of them. To our knowledge, this is the first prospective study of mould species in CF using molecular methods in Latin America. This study shows that Aspergillus sp., E. dermatitidis and Scedosporium sp. have a high frequency in CF patients from Argentina, and by far, A. fumigatus was the most commonly cultured species. Continuous clinical surveillance is required to detect the emergence of new fungal pathogens and to detect resistant or difficult-to-treat species capable of chronic colonizing the airways and of hematogenous dissemination in case of lung transplantation.

An unusual two-stage infection following a scolopendra bite

Background:Scolopendrae represent the best-known genus of centipedes. They are nocturnal general feeders with strong mandibles and venomous fangs which leave visible puncture marks at the bite site. The bite accidents occur during the warm rainy season and mostly take place on the extremities. Following the bite, the most common symptoms are mild: limited localized erythema, pain, swelling, local itching and burning sensation. However, more severe local and systemic sequelae can not be excluded.Method:we report the case of a 63-year-old man with fever and a widespread edema of the right hand and forearm, happened as a consequence of a Scolopendra Subspinipes bite. During the weeks following the bite, he developed a severe unusual superinfection via hematogenous dissemination, which required a double surgical debridement and a targeted intravenous antibiotic therapy.Results:the complete clinical recovery took over two months.Conclusions:Many victims of Scolopendra envenomation do not seek medical attention since most symptoms will resolve spontaneously. The case presented falls within the spectrum of those rare cases which escalate due to bacterial superinfection.

Pneumococcal perihepatitis due to hematogeneous dissemination

Perihepatitis is mainly caused by a direct extension of pelvic inflammatory disease, in which the causative pathogen is typically Neisseria gonorrhoeae or Chlamydia trachomatis. We herein discuss the case of a 61-year-old female patient who presented with a fever and right upper quadrant pain. Perihepatitis was diagnosed by contrast-enhanced computed tomography. She had no previous history of sexual activity, genital symptoms, remarkable physical findings or examination results indicative of pelvic inflammatory disease or other diseases. A blood culture detected Streptococcus pneumoniae, leading to the suspicion of hematogeneous dissemination. The patient was therefore treated with the appropriate antimicrobials. While invasive pneumococcal disease mainly results in bacteremic pneumonia, meningitis or endocarditis, the present case showed that it can also lead to perihepatitis; a blood culture is therefore useful for clarifying the infection route and pathogens in perihepatitis if the patient has no past history of sexual activity, genital symptoms or physical or other findings indicative of pelvic inflammatory disease.

Epidural spinal abscess from pneumonia in an immunocompetent patient: a case report.

Spontaneous spinal epidural abscesses are rare and often present high mortality due to late diagnosis. Spinal epidural abscesses are mainly formed by spondylodiscitis, osteomyelitis, hematogenous dissemination, or by local manipulation (surgery or epidural catheter placement). Recommended treatment is surgical medullar decompression followed by targeted antibiotic therapy. Authors document a case of a 51-year-old female, smoker, with bipolar disease and a recent hospitalization due to pneumonia. She was treated with antibiotic therapy with complete resolution of symptoms and laboratory abnormalities. After discharge, she reports periodic fever episodes, with no identified focus and not valued by her. About a month later, sudden paraparesis occurred, and an epidural abscess was diagnosed and it was submitted to surgical drainage. After spinal decompression, she underwent antibiotic therapy for twelve weeks with complete neurological recovery. Although uncommon, spinal epidural abscesses may be formed by contiguity lesions in the pleural space.

Miliary tuberculosis presenting with acute respiratory distress syndrome in a patient with down syndrome

Introduction. Miliary tuberculosis (TB) is a rare and potentially fatal form of disseminated TB. It is caused by a widespread haematogenous dissemination of Mycobacterium tuberculosis from an active caseous focus to different organs. Sometimes it can have an acute presentation with a rapidonset clinical deterioration and death. Miliary TB complicated with an acute respiratory distress syndrome (ARDS) requiring mechanical ventilation (MV) is rare, even in countries with a high incidence of TB. Case report. A 35-yearold woman with Down syndrome (DS) was admitted to the Clinic for Pulmonology, Clinical Centre Kragujevac, due to an evaluation of cough and weight loss during last 2 months. Laboratory findings revealed anaemia, leukocytosis, elevated C-reactive protein (CRP) and hypoalbuminemia. A chest x-ray showed bilateral reticulonodular shadows, predominantly in the mid and lower right lung lobes. A purified protein derivative (PPD) skin test and induced sputum smear for acid-fast bacilli (AFB) were both negative. On the fifth day following admission, her health condition suddenly declined, and after developing a moderate ARDS, she was put on the mechanical ventilation. Due to a high clinical suspicion of miliary TB and the fact that her life was compromised, an empirical anti-tuberculosis therapy was initiated. Despite all therapeutic and supportive measures, the patient expired 3 days later. The diagnosis of miliary TB was established post-mortem. Conclusion. Miliary TB should be kept in mind in patients with DS due to immunosuppression associated with deficient cell-mediated immunity. The development of ARDS as a complication of miliary TB is difficult to identify due to a low causal association. High clinical suspicion and a chest radiograph with a typical appearance of miliary pattern justify the initiation of empirical anti-tuberculosis treatment in such patients, as an attempt to change poor prognosis.

Long-Term Fever and Cytomegalovirus Infection in the Field of HIV Immunosuppression in Two Cases and Review of the Literature

Cytomegalovirus (CMV) infection is an infection that most often affects immunocompromised individuals with a seroprevalence of more than 80%. CMV co-infection is associated with increased mortality in HIV-infected individuals despite antiretroviral treatment. It has the potential for hematogenous dissemination to all the organs, but only becomes symptomatic when the viral load is high. This is especially possible when the human immune system is well controlled so that the individual infected with CMV generally remains asymptomatic, and possibly for a long period. Once the immune system fails, CMV infection becomes symptomatic. Diagnosis is not easy and is often done postmortem in developing countries with limited technical facilities. We report here two cases diagnosed at the Internal Medicine Service of the CNHU-HKM in Cotonou. The patients were infected with HIV and had a long term fever. The diagnoses were made on the basis of CMV serology. The first diagnosis was post-mortem, and the second patient died 48 hours after the start of the treatment.

Endogenous endophthalmitis due to Kingella Kingae infectious endocarditis

This report presents a rare case of endogenous endophthalmitis due to Kingella kingae infectious endocarditis. Endogenous endophthalmitis is a rare condition that has a systemic underlying cause, with hematogenic dissemination of a pathogen that will eventually reach and infect the eye. In this article, we present a case of a 54-year-old woman with fever, chills and decreased visual acuity and pain in the right eye. The slit-lamp exam showed conjunctival injection, anterior chamber reaction with a great amount of [...]

Disseminated Tumor Cells and Dormancy in Breast Cancer Progression.

Hematogenous dissemination of single cancer cells is a common phenomenon in patients with solid tumors. These cells may experience different fates: most will die during the process; some will grow into metastasis and some will persist in secondary homing sites for many years in a state referred to as dormancy. The mechanisms of this state are still not clear; single cancer cells can survive either by completely withdrawing from the cell cycle or by continuing to proliferate at a slow rate that is counterbalanced by cell death. Another hypothesis assumes that at least some of dormant tumor cells feature stem cell-like characteristics that may contribute to their extremely long half-lives and enhance chemotherapy resistance. Breast cancer is particularly known for prolonged periods of clinical freedom of disease (sometimes up to 20-30years), followed by a distant relapse. In this chapter, we explore the relationship between the clinical phenomenon of tumor dormancy and the disseminated tumor cells and discuss the potential implications for treatment.

Gene signature characteristic of elevated stromal infiltration and activation is associated with increased risk of hematogenous and lymphatic metastasis in serous ovarian cancer

BackgroundThe clinical significance of hematogenous and lymphatic metastasis in ovarian cancer has been increasingly addressed, as it plays an imperative role in the formation of both intraperitoneal and distant metastases. Our objective is to identify the key molecules and biological processes potentially related to this relatively novel metastatic route in serous ovarian cancer.MethodsSince lymphovascular space invasion (LVSI) is considered as the first step of hematogenous and lymphatic dissemination, we developed a gene signature mainly based on the transcriptome profiles with available information on LVSI status in the Cancer Genome Atlas (TCGA) dataset. We then explored the underlying biological rationale and prognostic value of the identified gene signature using multiple public databases.ResultsWe observe that primary tumors with increased risk of hematogenous and lymphatic metastasis highly express a panel of genes, namely POSTN, LUM, THBS2, COL3A1, COL5A1, COL5A2, FAP1 and FBN1. The identified geneset is characterized by enhanced deposition of extracellular matrix and extensive stromal activation. Mechanistically, both the recruitment and the activation of stromal cells, especially fibroblasts, are closely associated with lymphovascular metastasis. Survival analysis further reveals that the elevated expression of the identified genes correlates to cancer progression and poor prognosis in patients with serous ovarian cancer.ConclusionsOur findings indicate that tumor stroma supports the hematogenous and lymphatic spread of ovarian cancer, increasing tumor invasiveness and ultimately resulting in worse survival. Thus stroma-targeted therapies may improve the clinical outcomes in combination with cytoreductive surgery and chemotherapy.

Evidence that intra-amniotic infections are often the result of an ascending invasion - a molecular microbiological study.

Background Microbial invasion of the amniotic cavity resulting in intra-amniotic infection is associated with obstetrical complications such as preterm labor with intact or ruptured membranes, cervical insufficiency, as well as clinical and histological chorioamnionitis. The most widely accepted pathway for intra-amniotic infection is the ascension of microorganisms from the lower genital tract. However, hematogenous dissemination of microorganisms from the oral cavity or intestine, retrograde seeding from the peritoneal cavity through the fallopian tubes, and introduction through invasive medical procedures have also been suggested as potential pathways for intra-amniotic infection. The primary reason that an ascending pathway is viewed as most common is that the microorganisms most often detected in the amniotic fluid are those that are typical inhabitants of the vagina. However, thus far, no studies have shown that microorganisms in the amniotic cavity are simultaneously present in the vagina of the woman from which they were isolated. The objective of the study was to determine the frequency with which microorganisms isolated from women with intra-amniotic infection are also present in the lower genital tract. Methods This was a cross-sectional study of women with intra-amniotic infection with intact membranes. Intra-amniotic infection was defined as a positive culture and elevated concentrations of interleukin-6 (IL-6) (>2.6 ng/mL) in amniotic fluid and/or acute histologic chorioamnionitis and funisitis. Microorganisms isolated from bacterial cultures of amniotic fluid were taxonomically identified through matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF) and 16S ribosomal RNA (rRNA) gene sequencing. Vaginal swabs were obtained at the time of amniocentesis for the identification of microorganisms in the lower genital tract. The overall bacterial profiles of amniotic fluids and vaginal swabs were characterized through 16S rRNA gene sequencing. The bacterial profiles of vaginal swabs were interrogated for the presence of bacteria cultured from amniotic fluid and for the presence of prominent (>1% average relative abundance) operational taxonomic units (OTUs) within the overall 16S rRNA gene bacterial profiles of amniotic fluid. Results (1) A total of 75% (6/8) of women had bacteria cultured from their amniotic fluid that are typical residents of the vaginal ecosystem. (2) A total of 62.5% (5/8) of women with bacteria cultured from their amniotic fluid also had these bacteria present in their vagina. (3) The microorganisms cultured from amniotic fluid and also detected in the vagina were Ureaplasma urealyticum, Escherichia coli, and Streptococcus agalactiae. (4) 16S rRNA gene sequencing revealed that the amniotic fluid of women with intra-amniotic infection had bacterial profiles dominated by Sneathia, Ureaplasma, Prevotella, Lactobacillus, Escherichia, Gardnerella, Peptostreptococcus, Peptoniphilus, and Streptococcus, many of which had not been cultured from the amniotic fluid samples. (5) Seventy percent (7/10) of the prominent (>1% average relative abundance) OTUs found in amniotic fluid were also prominent in the vagina. Conclusion The majority of women with intra-amniotic infection had bacteria cultured from their amniotic fluid that were typical vaginal commensals, and these bacteria were detected within the vagina at the time of amniocentesis. Molecular microbiological interrogation of amniotic fluid from women with intra-amniotic infection revealed that the bacterial profiles of amniotic fluid were largely consistent with those of the vagina. These findings indicate that ascension from the lower genital tract is the primary pathway for intra-amniotic infection.

Study of the prevalence and pattern of fungal pneumonias in respiratory intensive care units

BackgroundFungal pneumonia is an infectious process in the lung caused by one or more endemic or opportunistic fungi. Fungal infection occurs following the inhalation of spores, after the inhalation of conidia, or by the reactivation of a latent infection. Hematogenous dissemination frequently occurs, especially in an immunocompromised host.Aim of the workTo assess the prevalence of fungal pneumonias in a group of respiratory ICUs and identify their pattern.Patients and methodsThis study was carried out on 60 patients who were admitted in respiratory ICUs of different hospitals: Ain Shams University and Military Hospitals from March 2018 till February 2019 to assess the prevalence of fungal chest infection in that group of patients and furthermore to identify their pattern. All patients were subjected to the following: history, clinical examination, radiology (plain chest radiograph and computed tomography of the chest), routine laboratory investigations and finally mycological analysis including direct microscopic examination and culture examination of the collected respiratory samples.ResultsThe mean age of all patients was 55.43 years. Regarding sex of the patients, the majority (76.67%) of patients were men, while 23.33% were women. Forty (66.67%) patients out of 60 patients with respiratory diseases had been culture positive for fungus and 20 (33.33%) patients had been culture-negative. The major fungal species encountered in this study were Candida species in 23 (57.5%) cases followed by Aspergillus species in 17 (42.5%) cases. Candida albicans was isolated in 23.33% of patients followed by Aspergillus nonfumigatus (18.33%) then Candida nonalbicans (15%), and finally Aspergillus fumigatus (10%).ConclusionFrom the current study, we can conclude that pulmonary fungal infection appears to be an important problem in patients with respiratory diseases especially patients who are admitted in respiratory ICUs regardless of their age or sex.

Cutaneous nocardiosis: A great imitator

Nocardiosis is caused by Gram-positive aerobic bacilli of the Nocardia genus, which are saprophytes living in the soil. It is a rare and opportunist disease with a localized or disseminated infection. When occurring in patients who are immunocompromised, involvement is usually systemic, most commonly represented by pulmonary disease. It can also be acquired through direct inoculation, entailing primary skin and subcutaneous tissue infections, frequently presenting as a localized nodular process. Cutaneous nocardiosis can manifest as a lymphocutaneous infection, actinomycetoma, superficial skin infection, or secondary infection from hematogenic dissemination. Diagnosis is made by identification of the organism in the culture of a clinical sample. Staining for acid-alcohol–resistant bacteria and, especially, Gram staining, is particularly relevant to obtain a rapid and presumptive diagnosis, while awaiting culture results. First-line medication is sulfamethoxazole-trimethoprim, which may be used with other antimicrobials, if necessary. Nocardiosis may be considered a major mimicker of several cutaneous diseases that present difficult, and often, delayed diagnoses.

278. CNS Blastomycosis: A Descriptive Analysis and Review of Diagnosis and Treatment

Background Blastomycosis is a systemic infection, well known to regions of the Southeastern and Ohio River Basin in the United States. Inhalation of the dimorphic fungus most often causes pulmonary manifestations. Hematogenous dissemination can affect various organs in immunocompromised hosts. Central Nervous System (CNS) involvement is a rare manifestation of Blastomycosis infection, accounting for 5%–10% of extrapulmonary involvement. It is important to diagnosis early and treat due to the increased morbidity in high-risk patients.MethodsOur study retrospectively reviewed cases from a Tertiary Care Facility in East Tennessee from 2011 to 2018 with the diagnosis of CNS Blastomycosis. Data collection included demographics, risk factors, varied clinical presentation, methods of diagnosis, treatment plans and outcomes.ResultsTotal of 8 CNS Blastomycosis cases were identified. Detailed demographics are presented in Table 1. The average age was 52 years, 7 (87.5%) were male. 6 (75%) were classified as immunocompromised. 6 of the 8 cases were tested for HIV, all of which were negative. MRI brain imaging was utilized in 7 (87.5%) cases, which demonstrated lesion enhancements, Table 2 and Images 1 and 2. CSF was collected in 6 (75%) patients. 5 patients (62%) presented with neurological complaints. All patients received Liposomal Amphotericin B (LAmpB), followed by a prolonged course of azoles. 5 (62%) developed acute renal insufficiency after starting Amphotericin B. 2 (25%) died.ConclusionCNS Blastomycosis is a rare diagnosis with increased morbidity and mortality. Obtaining brain imaging in addition to lumbar puncture can help in timely diagnosis of CNS Blastomycosis. Treatment involves lipid formulation of Amphotericin B followed by oral azole therapy, preferably voriconazole. Renal insufficiency was a common finding after this treatment. A high level of suspicion is crucial for recognition of CNS Blastomycosis in endemic regions of the Southeastern and Ohio River Basin. Disclosures All authors: No reported disclosures.

Infiltrating regulatory T cells promote invasiveness of liver cancer cells via inducing epithelial-mesenchymal transition

Background: Regulatory T (Treg) cells are a major component of the microenvironment of hepatocellular carcinoma (HCC) contributing to immunosuppression. The present study aimed to evaluate the effects of Treg cells on the invasion potential of HCC. Methods: Infiltrating Treg cells were isolated from fresh HCC tissues by immunomagnetic bead separation and detected by flow cytometry. Circulating tumor cells (CTCs) were detected using the CellSearch platform. The cell migration and invasion potentials were evaluated by Transwell assays. The cell viability was tested by the cell counting kit-8 (CCK8) approach, and the apoptosis rates were determined by flow cytometry. The concentrations of active transforming growth factor-β1 (TGFβ1) were measured by enzyme-linked immunosorbent assay. Results: Infiltrating Treg cells significantly correlated with the number of CTCs and vascular invasion (both P Conclusions: The involvement of infiltrating Treg cells in triggering the TGFβ1 signaling pathway and promoting the epithelial-mesenchymal transition (EMT) of cancer cells during tumor hematogenous dissemination is presumably responsible for increasing the invasiveness potential of HCC cells. Targeting Treg cells in microenvironments can be a promising therapeutic strategy to improve the prognosis for patients with HCC undergoing resection.

Tumor Microenvironment of Metastasis (TMEM) Doorways Are Restricted to the Blood Vessel Endothelium in Both Primary Breast Cancers and Their Lymph Node Metastases.

Cancer cells metastasize from primary tumors to regional lymph nodes and distant sites via the lymphatic and blood vascular systems, respectively. Our prior work has demonstrated that in primary breast tumors, cancer cells utilize a three-cell complex (known as tumor microenvironment of metastasis, or TMEM) composed of a perivascular macrophage, a tumor cell expressing high levels of the actin-regulatory protein mammalian enabled (Mena), and an endothelial cell as functional “doorways” for hematogenous dissemination. Here, we studied a well-annotated case–control cohort of human invasive ductal carcinoma of the breast and metastatic lymph nodes from a separate breast cancer cohort. We demonstrate that in primary breast tumors, blood vessels are always present within tumor cell nests (TCNs) and tumor-associated stroma (TAS), while lymphatic vessels are only occasionally present in TCN and TAS. Furthermore, TMEM doorways not only exist in primary tumors as previously reported but also in lymph node metastases. In addition, we show that TMEM intravasation doorways are restricted to the blood vascular endothelium in both primary tumors and lymph node metastases, suggesting that breast cancer dissemination to distant sites from both primary tumors and metastatic foci in lymph nodes occurs hematogenously at TMEM doorways. TMEMs are very rarely detected at lymphatic vessels and do not confer clinical prognostic significance, indicating they are not participants in TMEM-associated hematogenous dissemination. These findings are consistent with recent observations that hematogenous dissemination from lymph nodes occurs via blood vessels.

2662 A Unique Presentation of Concurrent Duodenal and Peritoneal Metastasis From Head and Neck Cancer

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.

2755 Metastatic Melanoma of the Stomach

INTRODUCTION: The GI tract is rarely affected by secondary tumors. One of the most common primary malignancies is melanoma, however, the stomach is a rare location for metastasis of malignant melanoma. We present a rare case of a patient who developed metastatic melanoma to the stomach. CASE DESCRIPTION/METHODS: An 82-year-old male with a prior history of melanoma presented with a chief complaint of hematemesis. Two weeks earlier, the patient had discovered an enlarged left axillary lymph node. His oncologist acquired a PET scan which demonstrated lower lobe pulmonary nodules and left axillary adenopathy. A biopsy of the axillary lymph node revealed metastatic melanoma. On the day of admission, he had several episodes of dark bloody emesis. Initial laboratory workup revealed a hemoglobin of 4.4. The patient was resuscitated and subsequently underwent an endoscopy. Innumerable black nodules were found scattered throughout the duodenum and stomach (Figure 1) along with a large ulcerating nodule with a depressed black center in the body of the stomach (Figure 2). Multiple cold biopsies revealed infiltration of the duodenal and gastric mucosa with discohesive malignant cells, abundant mitotic figures, and focal pigment formation. Immunohistochemical stains showed the cells to be positive for SOX10 and Melan-A (Figure 3). This confirmed metastatic melanoma within the upper GI tract and oncology was consulted for further management. DISCUSSION: The most common gastrointestinal metastatic sites from melanoma are the small bowel, followed by the colon, rectum and then stomach. The stomach is a rare location with a reported incidence of only 7%. Patients often present at an advanced stage of disease and prognosis is dismal. Median survival period from diagnosis is 4-6 months. Diagnosis is not commonly made before endoscopy as associated symptoms are non-specific and rarely present. Endoscopically, gastric melanomas are classified into 3 main morphological types: ulcerated melanotic nodules, submucosal masses with ulcerations, and mass lesions with necrosis and melanosis. The classic appearance is multiple, small nodules that can be pigmented or ulcerate to produce a bulls-eye appearance. The mechanisms underlying metastatic melanoma to the stomach are unclear. Four pathways may be involved in the metastatic spread of primary cancers to the stomach which includes peritoneal dissemination, hematogenous dissemination, lymphatic spread, and direct tumor invasion.

1342 A Rare Presentation of Lactobacillus Paracasei Endocarditis With Involvement of Aortic Prosthetic Valve in a Patient With Septic Shock Due to Acute Cholecystitis

INTRODUCTION: Endocarditis caused by Lactobacilli species is rare and usually manifests in patients with severe comorbidities, congenital heart disease, or prosthetic valves. Lactobacilli species are gram-positive coccobacilli mostly found in the gastrointestinal tract flora. Current literature shows an association of this bacterium with the use of probiotics. We hypothesize a possible association between acute cholecystitis and the occurrence of Lactobacillus endocarditis in a patient with no history of use of probiotics. CASE DESCRIPTION/METHODS: A 75-year-old female with a history of Birt-Hogg-Dube Syndrome with multiple spontaneous pneumothoraxes, COPD, aortic stenosis status post prosthetic aortic valve (AV) replacement, presented with acute respiratory failure and septic shock. She was diagnosed with acute cholecystitis, severe aortic regurgitation, and found to have lactobacillus bacteremia. We started her on empiric antibiotic coverage and later switched to penicillin G and gentamicin following three positive blood cultures for Lactobacillus paracasei. A transesophageal echocardiogram showed vegetation with emerging severe aortic regurgitation, degeneration, and perforation of AV leaflet when compared with echocardiogram one year ago. A CT-thorax demonstrated pan lobular emphysema with large cysts and pneumatoceles at the lung bases. Bacteremia persisted for two weeks after initiation of antibiotic therapy. Treatment with penicillin G and gentamicin was deemed necessary for up to 4 weeks after definitive surgical treatment. However, the patient's severe lung condition complicated preoperative clearance, and she was transferred to a specialized center for open-heart AV replacement. DISCUSSION: Very few cases of Lactobacillus endocarditis are reported in the literature. A handful of studies describe some implicated pathogenesis of the Lactobacillus in the blood as induced by cholecystitis. Other studies suggest that the increased presence of Lactobacillus in the respiratory tract in cases of severe lung pathology can lead to hematogenous dissemination to the heart valves. However, the association between Lactobacillus species and prosthetic valve material (and implication with endocarditis) is currently well-established. All things considered, and despite the lack of histopathology, we suggest that the source of Lactobacillus was likely the acute cholecystitis, and the presence of lung comorbidities and prosthetic AV further exacerbated the patient's condition.

2718 Gastric Pneumatosis in the Setting of Underlying Gastric Ulcer: An Uncommon Case Report Presentation

INTRODUCTION: Gastric Pneumatosis (GP) is a rare entity that is usually caused by emesis with forceful retching and inoculation of intraluminal gas into the stomach wall. GP is divided into two subtypes: emphysematous gastritis (EG) and gastric emphysema (GE). EG is a result of both direct inoculation and hematogenous dissemination of gas forming bacteria in the setting of immunosuppression, alcoholism, diabetes mellitus, and NSAID use. The clinical outcome tends to be septic shock and death. GE is less fatal and is diagnosed radiographically as air within the stomach wall. Conservative management is the treatment of choice. GE is commonly associated with gastric outlet obstruction, pulmonary injury, and other traumatic events. CASE DESCRIPTION/METHODS: A 56-year-old male nursing home resident, with Wernicke’s encephalopathy was sent to the ED after multiple episodes of hematemesis. On presentation, vital signs of HR:116, RR: 26. Physical exam exhibited diffuse abdominal tenderness, distension, decreased bowel sounds with noted involuntary guarding, but no rebound or rigidity. Decline in mental status and respiratory failure, prompted intubation. Initial labs showed leukocytosis of 15.2, normal Hb of 16.2, and AKI with Creatinine: 2.93. CT scan revealed severely distended stomach with gastric pneumatosis; distended small bowel loops, with a decompressed distal ileum and no discrete transition zone. CT showed also showed a large stool burden in the colon (Figure 1). EGD was initially deferred given high risk of gastric perforation. The patient was treated with bowel rest, NG tube decompression, IV fluids, PPI drip, and empiric Ceftriaxone and Metronidazole. Consequently, CT scan with IV contrast repeated on day 4 showed resolution of GP with patent mesenteric vasculature (Figure 2). EGD done on same day with evidence of diffuse moderate inflammation characterized by congestion (edema) in the entire stomach, and one non-bleeding linear gastric ulcer in the upper body, with a clean ulcer base (Forrest Class III) (Figure 3). Biopsies showed signs of chronic inflammation and reactive changes, as well as focal intestinal metaplasia in stomach antrum. DISCUSSION: Self-resolution of gastric pneumatosis after medical management is consistent with the benign course of GE, with reported positive clinical outcomes and low risk of recurrence. In this case, the patient’s gastric ulcer and vomiting associated with constipation contributed to his gastric emphysema. Absence of hepatoportal venous gas was a good prognostic sign.