Mucosal Bleeding Research Articles

Acquired von Willebrand Syndrome in left Impella supported cardiogenic shock patients

Abstract Background Bleeding is a main cause of morbidity and mortality in critically ill cardiogenic shock patients, supported by short-term percutaneous mechanical circulatory support (pMCS) devices. Bleeding not only occurs because of obligatory heparin and antiplatelet therapy (both required in the prevention of pump and stent thrombosis) but possibly also results from device-related coagulopathy. Similar to long-term ventricular assist devices, mechanical shear-induced acquired von Willebrand syndrome (AVWS) might further increase the bleeding risk. Therefore, we aimed to investigate the effect of left Impella percutaneous continuous flow pumps on the development of AVWS due to shear-induced excessive cleavage of large vWF multimers by the metalloproteinase ADAMTS-13, resulting in loss of high-molecular-weight vWF multimers. Methods Between March 2019 and January 2020, all cardiogenic shock patients supported by a left Impella and referred to a single tertiary ICU were studied. Both vWF Antigen (vWF:Ag) and vWF:GPIbR (ristocetin-induced binding of vWF to a recombinant wildtype Glycoprotein Ib fragment) levels were measured by chemiluminescent immunoassays using an AcuStar (Werfen) assay to determine the vWF:GPIbR /vWF:Ag ratio (normal range ≥1.0). VWF multimer analysis was performed by electrophoresis. On-pump analyses were performed 12h after implantation and off-pump analyses 12h after Impella explantation. Patients who died on-pump were excluded because of lack of paired data after explantation. Results Eight left Impella patients (four Impella CP, four Impella 5.0) were analyzed for AVWS. The vWF:GPIbR /vWF:Ag ratio was <1.0 in all patients on-pump (mean±SD 0.68±0.1 versus 1.1±0.15 off-pump (panel A; p=0.0018)) and thus AVWS was detected in all Impella-supported patients. The presence of AVSW was also confirmed by loss of large vWF multimers on-pump (panel B). Four patients (50%) had mucosal bleeds (epistaxis or gastrointestinal), none of them requiring transfusion. The mean rise in ratio 12h after pump removal was 0.35 which was also reflected by recovery of large multimers by electrophoresis (panel B). Conclusions Our data highlight the rapid onset and reversal of AVWS in all studied cardiogenic shock patients, supported by a left Impella pump. The determination of the GPIbR /vWF:Ag ratio with the AcuStar appears a reliable and faster test to detect AVWS as compared to vWF multimers electrophoresis. Further research into innovative pharmacological interventions (e.g. ADAMTS-13 inhibitors) should target pMCS-induced AVWS in an effort to reduce hemostatic complications in this critically ill ICU population. AVWS in Impella supported patients Funding Acknowledgement Type of funding source: None

Enfermedades de la hemostasia primaria. Púrpuras vasculares. Enfermedades de las plaquetas

Diseases of primary hemostasis. Vascular purpura. Platelet disorders: This update addresses the group of disorders that affects blood vessel walls and platelets, which are a fundamental part of primary hemostasis. They are divided into purpura (vascular involvement) or quantitative or qualitative platelet abnormalities and can be congenital or acquired. The incidence of many of these entities is low; some are considered rare diseases. The typical hemorrhagic manifestations include the appearance of cutaneous and mucosal bleeding with trauma. Some congenital coagulopathies form part of groups of syndromes in which involvement goes beyond bleeding symptoms, requiring a multidisciplinary approach. In all coagulopathies, it is important to take a thorough personal and family medical history. In this regard, platelet function and aggregation tests are useful. More and more, the genetic alterations behind these cases are becoming known, with molecular diagnostic techniques gaining greater importance. In congenital forms, treatment is symptomatic, targeted according to the localization, and accompanied by multidisciplinary teams. For cases with platelet function involvement, a platelet transfusion can also be opted for.

Comparison of histomorphometric characteristics of dorsal colon and pelvic flexure biopsy specimens obtained from horses with large colon volvulus that underwent resection.

To determine the degree of histomorphometric damage in dorsal colon and pelvic flexure biopsy specimens (DCBSs and PFBSs, respectively) obtained from horses with large colon volvulus (LCV) and assess the accuracy of predicting short-term outcome for those horses on the basis of DCBS or PFBS characteristics. 18 horses with ≥ 360° LCV that underwent large colon resection. During surgery, biopsy specimens from the dorsal colon resection site and the pelvic flexure (when available) were collected from each horse. Interstitial-to-crypt (I:C) ratio (ratio of the lamina propria space occupied by the interstitium to that occupied by crypts), hemorrhage within the lamina propria (mucosal hemorrhage score [MHS] from 0 to 4), and percentage losses of glandular and luminal epithelium were determined in paired biopsy specimens and compared to determine optimal cutoff values for calculating the accuracy of DCBS and PFBS characteristics to predict short-term outcome (survival or nonsurvival after recovery from surgery). Paired biopsy specimens were obtained from 17 of the 18 horses. The I:C ratio and percentage glandular epithelial loss differed between DCBSs and PFBSs. For DCBSs, an I:C ratio ≥ 0.9 and MHS ≥ 3 each predicted patient nonsurvival with 77.8% accuracy. For PFBSs, an I:C ratio ≥ I and MHS ≥ 3 predicted patient nonsurvival with 70.6% and 82.4% accuracy, respectively. Although different, histomorphometric measurements for either DCBSs or PFBSs could be used to accurately predict short-term outcome for horses with LCV that underwent large colon resection, and arguably PFBSs are easier to collect.

Association of ABO blood group with bleeding severity in patients with bleeding of unknown cause

AbstractBlood group O has been associated with an increased bleeding tendency due to lower von Willebrand factor (VWF) and factor VIII (FVIII) levels. We explored whether blood group O is independently associated with bleeding severity in patients with mild-to-moderate bleeding of unknown cause (BUC) in the Vienna Bleeding Biobank cohort. Bleeding severity was recorded with the Vicenza bleeding score (BS). Blood group O was overrepresented in 422 patients with BUC compared with its presence in 23 145 healthy blood donors (47.2% vs 37.6%; odds ratio, 1.48; 95% confidence interval [CI], 1.22-1.79). The BS and the number of bleeding symptoms were significantly higher in patients with blood group O than in patients with non-O after adjustment for VWF and FVIII levels and sex (least-square [LS] means of BSs: 6.2; 95% CI, 5.8-6.6 vs 5.3; 4.9-5.7; and of number of symptoms: LS, 3.5; 95% CI, 3.2-3.7 vs 3.0; 2.8-3.2, respectively). Oral mucosal bleeding was more frequent in those with blood group O than in those with other blood types (group non-O; 26.1% vs 14.3%), independent of sex and VWF and FVIII levels, whereas other bleeding symptoms did not differ. Patients with blood group O had increased clot density in comparison with those with blood group non-O, as determined by rotational thromboelastometry and turbidimetric measurement of plasma clot formation. There were no differences in thrombin generation, clot lysis, or platelet function. Our data indicate that blood group O is a risk factor for increased bleeding and bleeding severity in patients with BUC, independent of VWF and FVIII levels.

Clinical profile of thrombocytopenia in tropical infectious diseases

Background: In an infant or child thrombocytopenia can occur due to large spectrum of illness ranging from tropical infection to malignancy or bone marrow failure. Management is decided by the severity of thrombocytopenia, associated risk factors and underlying illness. Children with thrombocytopenia may be asymptomatic – detected by complete blood count for some other clinical issue or symptomatic-presenting with mucosal and/or cutaneous bleeding and rarely central nervous system bleed. Aim of this research is to study the distribution of patients with thrombocytopenia, their grading according to platelet counts and etiology with special focus to infective causes, other complications in these infections and recovery from thrombocytopenia.Methods: This is an observational analytical retrospective study. 100 randomly selected pediatric patients (6 months to 12 years) admitted in pediatric ward with documented thrombocytopenia (platelet count <150,000/ul) on admission or at any point of time during hospitalisation are enrolled and analyzed.Results: 91% patients have thrombocytopenia associated with infective causes, of which 44% have dengue. 7 patients in study have bleeding manifestations and 3 required platelet transfusion. 50% patients with dengue with thrombocytopenia have leucopenia and 2% have pancytopenia. 57.1% patients with enteric fever with thrombocytopenia show elevated alanine aminotransferase (ALT) levels. Mean platelet recovery time is 2 to 4 days for various infections.Conclusions: Majority of patients do not have bleeding manifestations, and they are mainly seen with severe thrombocytopenia associated with infections. Requirement of platelet transfusion is not common and is seen only in patients with severe thrombocytopenia with significant bleeding manifestation.

Surgical management of the patient with factor V deficiency: a case report

<p class="abstract">Factor V (FV) is a rare bleeding disorder that its incidence is one in a million. Patients with FV deficiency have typically mucosal bleeding and prolonged bleeding after an invasive procedure. There are no certain treatment modalities and there is no product of FV concentrates in the markets. The bleeding diathesis and protect the ovarian viability are a challenge as an opposite situation for treatment options and ovarian preservation after detorsion is controversial. We aimed to provide ovarian blood-stream, control bleeding and protect thromboembolism from the patient with all of our treatment in the light of literature and a few case reports. </p>

Computer-Aided Diagnosis With Monochromatic Light Endoscopy for Scoring Histologic Remission in Ulcerative Colitis

Computer-Aided Diagnosis With Monochromatic Light Endoscopy for Scoring Histologic Remission in Ulcerative Colitis

Diffuse Hemorrhagic Enterocolitis in the Setting of 2019 Coronavirus

A 47-year-old woman with diabetes diagnosed with COVID-19 was transferred to our institution for extracorporeal membrane oxygenation therapy. Gastroenterology was consulted because of worsening diarrhea, which started before transfer, and new hematochezia after extracorporeal membrane oxygenation was discontinued. Contrast-enhanced computed tomography demonstrated diffuse small and large bowel wall thickening and edema (Figure A, arrows), resulting in ribbon-like bowel. Upper endoscopy and colonoscopy were pursued. Atrophic and friable gastric and duodenal mucosa was found. Diffuse congested, friable, and hemorrhagic mucosa (Figure B) was seen throughout the colon and terminal ileum. Biopsies from the ileum and colon (Figure C) showed complete loss of glandular epithelium without associated increase in lamina propria inflammation despite the degree of epithelial damage. Supportive management was pursued. Extracorporeal membrane oxygenation is associated with immune system activation, leading to a systemic inflammatory response and a procoagulant state that can ultimately cause organ injury, such as ischemic colitis. COVID-19 has demonstrated a wide range of gastrointestinal manifestations. We present a case of diffuse hemorrhagic enterocolitis with endoscopic biopsies showing diffuse mucosal damage with relative lack of inflammatory response. This histologic pattern of injury resembles immunosuppressed states and apoptosis-mediated processes. Based on timeline and findings, the gastrointestinal tract injury is likely related to severe COVID-19.

A Comparative Study to Assess the Knowledge Regarding Dengue Fever and its Prevention among All Women at the Selected Urban and Rural Areas of Ratia (Fatehabad)

Dengue infection is a mosquito-borne arboviral infection. An important criterion to consider in the diagnosisof dengue infection is history of travel or residence in a dengue-endemic area within 2 weeks of the onsetof fever. The spectrum of dengue virus infection ranges from an asymptomatic or undifferentiated febrileillness to severe infection. Criteria for diagnosis of probable dengue include history of travel or residence ina dengue-endemic area, plus high grade fever of acute onset and two of the following signs and symptoms:nausea/vomiting, rash, severe aches and pains (also called ‘break bone fever’), positive tourniquet test,leukopenia, and any warning sign. Presence of any of the following warning signs–abdominal pain ortenderness, persistent vomiting, clinical fluid accumulation, mucosal bleeding, lethargy, restlessness, liverenlargement greater than 2 cm, and an increase in hematocrit concurrent with rapid decrease in plateletcount–will require strict observation and medical intervention.

Von Willebrand Disease, A Rare Cause of Massive Upper GI Bleeding: A Case Report

von Willebrand Disease (VWD) is the most common inherited bleeding disorder. It occurs due to either qualitative or quantitative defect of von Willebrand Factor (VWF). VWF is a large multimeric glycoprotein necessary for platelet aggregation and adhesion to the subendothelium following any vascular injury. Typical presentation of VWD patient include mucosal bleeding, easy bruising and bleeding following minor trauma. Rarely, these patients may present with gastro intestinal bleeding. The treatment of choice in mild forms of VWD is the synthetic agent desmopressin. In patients with severe form or in children who do not response to desmopressin, the appropriate treatment is a VWF rich factor VIII concentrate. There are few case reports of VWD with upper gastrointestinal (UGI) bleeding. So, we report a case of 9 years old female child who was admitted at Bangabandhu Sheikh Mujib Medical University in Paediatric Gastroenterology Department with the complaints of recurrent UGI bleeding for 3 years. She also had history of spontaneous gum bleeding, easy bruising, echymosis, prolong bleeding following minor trauma since early age. After appropriate evaluation of the patient including history and relevant investigation, she was diagnosed as a case of VWD with GI bleeding. We report this as it is a rare presentation of VWD.
 Bangladesh J Child Health 2019; VOL 43 (3) :188-191

WHO 2009 Warning Signs as Predictors of Time Taken for Progression to Severe Dengue in Children

To identify WHO 2009 warning signs that can predict time taken for progression to severe dengue in a pediatric population. Prospective analytical study over 1 year and 2 months. Tertiary care center. 350 children aged 1 mo-12 y with serologically confirmed dengue without co-morbidities/co-infections; conse-cutive sampling. At admission, clinical and laboratory details were noted. Disease progression, time of onset of each warning sign, hematocrit, and platelet counts were recorded daily till discharge/ death. If progressing to severe dengue, its time of onset was noted. Time to event analysis with Log Rank test, Kaplan Meier plots and Cox Proportional Hazards Model was done. Primary outcome was time interval from onset of first warning sign to onset of severe dengue (defined as per WHO 2009 guidelines). Predictors were WHO 2009 warning signs: abdominal pain, lethargy, persistent vomiting, mucosal bleed, clinical fluid accumulation, hepatomegaly >2 cm, hematocrit ≥0.40 and platelet count <100x109/L. Among 350 children followed up completely till discharge/death, 90 developed severe dengue (event) while 260 did not (censored). Median age of study population was 7.75 y. Clinical fluid accumulation [(P=0.002, Hazard Ratio (HR) 2.19, 95% CI 1.33-3.60)] and hematocrit ≥0.40 [(P=0.009, HR (95%CI) 1.715, (1.13-2.60)] were significant in univariate analysis. Final multivariate model includes clinical fluid accumulation [(P=0.02, HR (95%CI) 1.89, (1.116-3.202)], hematocrit ≥0.40 (P=0.07), mucosal bleed (P=0.56) and persistent vomiting (P=0.32). WHO warning signs that predict time taken for progression to severe dengue in children include clinical fluid accumulation, hematocrit ≥0.40, persistent vomiting and mucosal bleed. Study results have implications in policy making and practice guidelines to triage children attending a health care facility with or without warning signs.

S3457 Unusual Gastrointestinal Manifestation of Fabry Disease

INTRODUCTION: Fabry’s disease (FD) is a rare lysosomal storage disease caused by an X-linked deficiency of α-galactosidase A, resulting in intracellular accumulation of glycolipids, globotriaosylceramide (Gb3) in various tissues. Primarily affecting the skin (angiokeratomas), kidney (proteinuria and renal failure), heart (cardiomyopathy and arrhythmias), nervous system (acroparaesthesia, and autonomic neuropathy). Gastrointestinal (GI) manifestations are common and include diarrhea, nausea, abdominal pain, early satiety, and diverticular disease typically attributed to enteric neuropathy and myopathy caused by the accumulation of (Gb3). CASE DESCRIPTION/METHODS: A 69-year-old male with a past medical history of FD on agalsidase-β bi-weekly infusion, chronic intermittent diarrhea, autonomic neuropathy, chronic kidney disease, and atrial fibrillation on Coumadin, presented with hematochezia, four hours from his presentation, associated with blood clots, lightheadedness, diaphoresis, and near syncope. At presentation, vitals were stable, the abdomen was soft and non-tender, digital rectal exam was remarkable for scant bright red blood, and guaiac positive stool. Routine laboratory testing was significant for 8.7 g/dl decreased from baseline 13 gm/dL, BUN 61 mg/dL, Creatinine 2.57 mg/dL, lactic acid 3.9 mg/dL, INR 3.8. Therapy initiated with oral vitamin K and fresh frozen plasma for reversal of Coumadin effect. With further bloody bowel movements, hemoglobin dropped to 6.8 gm/dL requiring blood transfusion. Tagged RBC scan was negative for active bleeding, esophagogastroduodenoscopy (EGD) showed mild non-bleeding erythematous antral gastropathy, colonoscopy revealed normal mucosa without a source of bleeding. In a few days hematochezia resolved, the patient tolerated oral intake, Coumadin was resumed, and the patient was discharged home with plans for virtual capsule endoscopy as an outpatient. DISCUSSION: Gastrointestinal bleeding is a rare manifestation of FD. Cutaneous angiokeratomas are vascular lesions caused by upper dermal vessels ectasia, affect 70% of FD patients. The absence of a clear source of GI bleeding in this case on EGD, increase the likelihood of mucosal angiokeratomas bleeding in the small intestine. Mucosal angiokeratomas have been reported as a cause of life-threatening GI bleeding, which can be found anywhere in the GI tract mucosa. Given the high likelihood of arrhythmias requiring anticoagulation in FD, physicians should be more vigilant of the possibility of severe GI bleeding.

S2764 A Novel Cause of Odynophagia From Unintentional Foreign Body Introduction During EGD With Dilation

INTRODUCTION: Esophageal dilation is a valuable treatment option for multiple symptoms including dysphagia. Like all procedures, dilation carries its own unique risks including iatrogenic injury. We present a patient who underwent dilation and suffered a medical error when a sterilization indicator strip was inadvertently placed and left in her esophagus. CASE DESCRIPTION/METHODS: An 88-year-old female presented to a referring hospital with suspected food bolus impaction. The week prior, she had undergone an esophageal dilation for solid food dysphagia. The day after the procedure, she developed intermittent, spasm-like substernal chest pain. Her symptoms worsened to include dysphagia, hematemesis, regurgitation, and inability to tolerate her saliva which prompted her to return to the hospital. On arrival, her vitals, labs, EKG, and CXR were within normal limits and without acute findings. A CT scan of the chest demonstrated a dilated esophagus with intraluminal contents at the upper thoracic inlet. Upon transfer to our facility, GI recommended a trail of glucagon. She continued to have symptoms, which prompted an evaluation with EGD. This revealed a stiff, plastic-like foreign body in the upper esophagus. The distal edge was embedded within the esophageal mucosa causing ulceration and raising concern for impending perforation (Figure 1). Attempts were made to remove the object using a raptor grasper. Eventually, the object was removed with a jumbo oval snare. There were no deep mucosal tears or active bleeding noted after removal (Figure 2). The object was identified as a sterilization indicator strip which was almost certainly introduced at her dilation the week prior (Figure 3). An esophagram revealed moderate esophageal dysmotility without stricture, mass, or evidence of contrast extravasation. She was ultimately discharged home on a PPI with outpatient GI follow-up. DISCUSSION: In the patient presented, we do not know the type of dilator used or if any complications were encountered during dilation. We suspect the indicator strip was introduced either through a pre-dilation EGD or stuck to the dilator itself. Indicator strips can take a concave shape which allows them to adhere to round equipment reprocessed for GI procedures. Given the reduced lighting during these procedures, careful inspection of equipment is necessary to avoid missing these objects. Perhaps by standardizing a post-dilation EGD to evaluate for complications, this could have been addressed sooner.Figure 1.: Foreign Body Located in the Proximal Esophagus.Figure 2.: Esophagus following Foreign Body Removal.Figure 3.: Foreign Body after Removal from the Esophagus.

Evaluation of a Disease State Stewardship Intervention for Urinary Tract Infections at an Academic Medical Center

Background: Urinary tract infections (UTIs) are often misdiagnosed and mismanaged. Disease state stewardship initiatives targeting UTIs through the development of institutional guidelines and real-time prospective audit and feedback (PAAF) on provider management may have a significant impact on the overuse of antimicrobials. Objective: Our study evaluated the effectiveness of a UTI focused disease state stewardship intervention by assessing institutional guideline adherence before and after implementation. Methods: This retrospective quasi-experimental study was conducted at a tertiary-care academic medical center. Patients &gt;18 years of age receiving antimicrobials for a UTI were included. A previously performed retrospective review of UTI management from September-November 2017 was used as the baseline. The UTI management guideline was implemented in July 2018, and service lines were educated. A PAAF initiative began in June 2019, whereby the antimicrobial stewardship team performed daily reviews of patients receiving antimicrobials for UTIs. Data was collected on their management, and providers were contacted in real time with recommendations based on the institutional guideline. Patients reviewed June–October 2019 were included in the postimplementation analysis. Patients were excluded if they were pregnant, underwent a urological procedure with risk of mucosal bleeding, or were an outside hospital transfer already on UTI therapy. The primary outcome of this study was to evaluate guideline adherence before and after the implementation of PAAF for the management of UTIs. Results: In total, 198 patients in the preintervention group and 246 in the PAAF group were included. The emergency department was the primary ordering service of urinalyses (60.1% vs 66.1%; P = .2287) in both periods and altered mental status as the main indication for testing (35.2% vs 31.3%; P = .5465). Treatment of asymptomatic bacteriuria and pyuria decreased significantly between the 2 periods: 74.8% versus 36.2% (P = .0001). Appropriate ordering of urinalyses (33.8% vs 68.3%; P = .0001) and urine cultures (29.3% vs 61.0%; P = .0001) also improved in the PAAF group. Recommendations made during PAAF included therapy discontinuation (66.7%), antimicrobial therapy change (15.5%), or duration modification (15.5%), and 59.5% of first interventions were accepted. Overall guideline compliance significantly improved from 13.1% in the preintervention period to 26.1% in the PAAF period (P = .0011). Conclusions: A UTI disease state intervention was associated with significant reductions in the treatment of asymptomatic presentations as well as an improvement in overall guideline adherence. We believe that this approach represents a powerful stewardship strategy for decreasing unnecessary antimicrobial usage.Funding: NoneDisclosures: None

COUGH-INDUCED DIFFUSE BRONCHIAL HEMORRHAGE

SESSION TITLE: Medical Student/Resident Procedures Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Bleeding from the tracheobronchial tree is usually caused by neoplasms, bronchitis, bronchiectasis, mucosal infections, and/or iatrogenic mucosal erosions. We present a rare case of petechial tracheobronchial hemorrhage developing after a severe bout of cough. CASE PRESENTATION: An 81-year-old male with past medical history of Acquired immunodeficiency syndrome (AIDS), combined pulmonary fibrosis and emphysema, pulmonary hypertension, and chronic hypoxemia on supplemental oxygen (3 L/min), presented with gradually worsening dyspnea and non-productive cough over 6 months. Computed tomography (CT) scan of the chest showed a right upper lobe cavitary lesion for which further evaluation with diagnostic flexible fiberoptic bronchoscopy was planned. His home medications included low dose aspirin (81 mg) daily for the primary prevention of cardiovascular disease. He did not have any prior history of hemoptysis or coagulopathy. The patient received aerosolized topical anesthesia with nebulized lidocaine orally prior to bronchoscopy after which he developed a strong coughing fit. Patient was intubated with a laryngeal mask and flexible bronchoscopy was performed under monitored anesthesia care using Propofol. Inspection of the airways incidentally showed numerous mucosal petechiae with oozing of blood in the entire tracheobronchial tree distal to the vocal cords [Figure 1]. Patient was admitted due to worsening hypoxia and hemoptysis post procedure. He had mild hemoptysis for the next two days after which it resolved without any intervention. Broncho alveolar lavage cultures showed Mycobacterium avium intracellulare complex for which he was treated. DISCUSSION: We describe an unusual case of diffuse bronchial hemorrhage that, given the clinical course, developed due to severe coughing fit immediately prior to bronchoscopy. Only a few cases of cough induced diffuse bronchial hemorrhage, also called as the "hemorrhagic bronchial mucosa syndrome", have been previously reported [1-3]. The presence of mucosal petechiae with evidence of bleeding is a characteristic finding and usually improves with conservative management. It has been postulated that high intrathoracic pressures during coughing can increase intravascular pressure resulting in local vessel damage and bleeding [3]. Immunocompromised status due to AIDS, old age, use of aspirin, and pulmonary hypertension may have been additional risk factors predisposing to hemorrhage in this case. CONCLUSIONS: Diffuse bronchial hemorrhage or "hemorrhagic bronchial mucosa syndrome” is a rare complication that can occur during bronchoscopy due to severe coughing and measures to prevent coughing should be considered. Reference #1: Panjwani A. Hemorrhagic bronchial mucosa syndrome. The Egyptian Journal of Internal Medicine. 2015;27(4):151-153. Reference #2: Hira HS. Cough-induced Tracheobronchial Mucosal Bleeding. J Bronchology Interv Pulmonol. 2011;18(1):51-52. Reference #3: Milman N. Diffuse bleeding from the bronchial mucosa on flexible bronchoscopy in lung transplanted patients: 'the hemorrhagic bronchial mucosa syndrome'. Respiration. 2009;77(4):416-419. DISCLOSURES: No relevant relationships by Steven Shaw, source=Web Response No relevant relationships by Abhishek Singla, source=Web Response

Effect of endotracheal tube plus stylet versus endotracheal tube alone on successful first-attempt tracheal intubation among critically ill patients: the multicentre randomised STYLETO study protocol

IntroductionTracheal intubation is one of the most daily practiced procedures performed in intensive care unit (ICU). It is associated with severe life-threatening complications, which can lead to intubation-related cardiac arrest....

S2601 A Curious Case of Transient Autoimmune Hepatitis

INTRODUCTION: Autoimmune Hepatitis (AIH) is a rare disease among human immunodeficiency virus (HIV) infected individuals due to their impaired immune system. Opportunistic hepatotropic viruses such as cytomegalovirus (CMV) have been described to trigger AIH. We report a case of a young male with suspected AIH who was ultimately diagnosed with HIV and disseminated CMV. There have been reports of CMV infection triggering AIH and awareness of the association between CMV and AIH is important as the clinical presentation of these entities may overlap ultimately resulting in erroneous diagnoses and management in an already immunocompromised population. CASE DESCRIPTION/METHODS: A 34 year-old-male who presented for evaluation of chronically elevated liver enzymes. He referred no significant symptoms. Denied illicit drug and alcohol use. Liver workup with negative hepatitis panel, positive ASMA 1:160 with elevated IgG of 2174 md/dL. Also found with acute HIV. During follow-up visit patient reported chronic watery diarrheas. He underwent liver biopsy due to suspected AIH with findings of one hepatocyte with an inclusion body consistent with CMV. In addition, pericellular fibrosis with early bridging fibrosis with increase in plasma cells suggestive of AIH. Laboratories with positive CMV IgG and CMV DNA quantitative of 75944 IU/ml. Sigmoidoscopy with diffuse, friable, erythematous lesions from 40 cm to rectum. Biopsies consistent with CMV colitis. Later he developed CMV retinitis. He was started on ganciclovir and HAART therapy with normalization of liver enzymes. DISCUSSION: AIH is an uncommon disease with a global incidence that ranges from 0.7 to 2 per 100,000 population per year. The incidence of AIH in HIV patients is even lower and this diagnosis is often not suspected as it is counterintuitive in the setting of impaired immune system. Most AIH cases reported in HIV patients are associated with the immune reconstitution phase and rarely as a consequence of infection with opportunistic hepatotropic viruses as appeared to be in our case. The mechanism of AIH overlapping with CMV is believed to be molecular mimicry via cross reactivity between CMV exons and cytochrome CYP2D6. This case illustrates the importance of considering hepatotropic viruses when AIH is suspected given their potential for triggering AIH. The treatment strategies of these entities are vastly different highlighting the importance of ensuring a correct diagnosis at time of presentation.Figure 1.: Hepatocyte with inclusion consistent with Cytomegalovirus.Figure 2.: Diffuse friable erythematous lesions consistent with Cytomegalovirus colitis.Figure 3.: Focal acute colitis with areas of mucosal hemorrhage and Cytomegalovirus inclusions.

An unusual immune thrombocytopenia case associated with dietary supplements containing 3G (Green tea, Ginseng and Guarana)

Immune thrombocytopenia (ITP) is caused by autoantibodies to platelet antigens. Ginseng, a herbal remedy, inhibits platelet aggregation as well as green tea and guarana. We present a case of secondary ITP due to food supplement that contains ginseng, guarana and green tea, which is not previously reported in medical literature. A 39-year-old man was admitted to our clinic because of 2 days history of oral mucosal hemorrhage and recently developed skin lesions on extensor surfaces of bilateral upper extremity and both ankles. Platelet count was 5,470/mm3. He was diagnosed with secondary ITP, possibly due to herbal supplement contained green tea, ginseng and guarana, which patient was received for 4-5 days about 1 month ago. He responded well to the treatment with methyl prednisolone. Since herbal medicines and dietary supplements have many toxic effects it should be kept in mind that secondary ITP may develop during supplementation with these herbal products.

Improving Animal Model of Induced Colitis by Acetic Acid in Terms of Fibrosis and Inflammation Incidence in the Colon

Background : One of the animal models of colitis is induced by acetic acid, which mimics some features of ulcerative colitis disease. In order to increase the similarity of this model to human IBD and determine the suitable duration of acid contact to the colon and the day of induction of colitis were investigated in this study. Methods Fifty rats were randomly separated into five groups (n = 10) with different durations (30 s, 5, 10, and 20 min) of exposure of the colon to 4% acetic acid and colitis was investigated for 0-9 days. The extent of the mucosal ulcers, colon tissue thickening, and mucosal bleeding were scored by the Gerald classification system score. Slides of tissues were prepared for pathologic assay using the modified Wallace method. Results In all groups, inflammation was severe three days after the colitis induction, but no inflammation was observed in the 30 s group after five days. Acid contact with the colon surface did not result in fibrosis for the 30 s and the colon fibrosis was mild in 5 min group and severe in 10 and 20 min groups. The tissue damage was higher in groups of 20, 10, 5 min, and 30 s, respectively. Over time, the recovery rates in the 30 s and 5 min groups were higher than other groups. Conclusion Our results showed that the evaluation of the disease process from 3 days to nine days after a 10 min contact of acid to the colon is a suitable model that mimics the histological features of the disease.

Parahaemophilia: A Rare Case Report

Parahaemophilia or Owren’s diseaseis a rare haemorrhagic disorder occurs due to congenital and frequently familial deficiency of Factor V.It is characterized by epistaxis, bruising, mucosal bleeding, soft tissue bleeding and haemarthrosis. We report a case of 6 year old female patient with overlapping features with other haemorrhagic disorder. With the complaints of recurrent episodic per rectal bleeding, patient was evaluated at different hospitals in Chattagram and was diagnosed as a case of Haemophilia B and treated accordingly. As her condition was not improved expectedly, she was referred to Armed Forces Institute of Pathology (AFIP) for further evaluation. The lab tests showed prolongation of prothrombin time (PT) and activated partial thromboplastin time (APTT), with normal bleeding time (BT) and thrombin time (TT). Coagulation factors assay revealed a significant decrease of factor V, 1% of normal range. Other coagulation factors are normal. She was treated with FFP and recovered four weeks after treatment.&#x0D; J Bangladesh Coll Phys Surg 2020; 38(4): 205-208