Mucosal Involvement Research Articles

Accurate Diagnosis After Multidisciplinary Tumor Board: A Case Report of Cholangiocarcinoma

Multidisciplinary tumor boards (MDTBs) provide a venue for discussion of diagnosis, staging, and treatment of patients with cancer. MDTBs have been shown to improve diagnostic accuracy and staging, exemplified in this patient with a hepatic flexure mass on colonoscopy and initial pathology suggestive of primary colonic adenocarcinoma with surface mucosal involvement. However, subsequent CT imaging revealed a biliary malignancy invading the colon. Discussion at a MDTB facilitated radiology-pathology correlation, with subsequent immunohistochemical stains compatible with a cholangiocarcinoma with transmural colonic invasion. Prompt and accurate diagnosis after the MDTB enabled the oncology team to offer the proper treatment approach.

An asymmetric morbilliform eruption in an adult male

An asymmetric morbilliform eruption in an adult male

Oral mucosal involvement and frequency of Pemphigus vulgaris inpatients at Khartoum

Pemphigus Vulgaris(PV) is a potentially life-threatening autoimmune disease with a high mortality rate and oral manifestations often being the earliest symptoms. The aim of this study is to describe the frequency of Pemphigus Vulgaris in terms of Age, gender, residence and geographic origin, to study its frequency, type, and site distribution of Oral mucosal lesions (OMLs), analyze its association with skin lesions and to correlate it with systemic diseases and mortality rate.A retrospective hospital based study was done using in-patient records at Khartoum Dermatology and Venereal diseases Teaching Hospital from Jan 2010 to Dec 2019. Clinical evaluation and histopathological records were the method of diagnosis. Study variable such as socio–demographic data, oral mucosal lesions (type, site, distribution), presence of skin lesions, association with chronic systemic diseases, mortality were used in the study. A structural data collection sheet questionnaire, modified from the standard (WHO) questionnaire of OMLs, was used.In this study, 321 (47.3%) patients out of 678 patients were diagnosed with PV, of which the most common age group reported was 31-50 years (41.8%), females (68.6%) were more affected. Out of 321 PV cases, OML reported in 227 (70.7%) patients. The majority of OMLs (81.9%) were reported in more than one site, among which the most common reported site was Lip (23.5%) and (32.4%) of PV cases were associated with chronic systemic diseases, (10.9%) with mortality, of which, 29 (82.9%) out of 35 cases, reported with OMLs and peak age group of mortality was (41-50 years) (41.5%) among which female had higher mortality (78.9%).PV was seen to be the most commonly manifesting mucocutaneous disease among the study population. Majority of the cases had oral mucosal lesions in concordance with previous studies and literature.

Clinical Characteristics of Anaphylaxis in Children Aged 0–16 Years in Xi’an, China

Introduction: Anaphylaxis is a serious systemic hypersensitivity reaction that usually has a rapid onset and may cause death. The aim of this study was to clarify the clinical characteristics of anaphylaxis in children of all ages in Xi’an, China. Methods: A retrospective study was conducted on anaphylaxis cases in the emergency department of the Affiliated Children’s Hospital of Xi’an Jiaotong University between January 1, 2016, and July 1, 2021. The statistical methods used were the χ² test, Fisher’s exact test, and Z-test. Results: A total of 110 cases of anaphylaxis were collected: 70% were male, 13 were <1 year old, 17 were 1–2 years old, 42 were 3–6 years old, 38 were 7–16 years old, 10 (9.1%) had ≥2 anaphylaxis, and 75 (68.1%) had a previous history of allergy. The triggers of anaphylaxis were analyzed: 50 cases (45.5%) were induced by food, 37 cases (33.6%) by drugs, 6 cases (5.5%) by insect bites, 4 cases (3.6%) by exercise, and 12 cases (11.8%) by unknown causes. Common food allergens were milk (20%, 10/50), buckwheat (16%, 8/50), eggs (14%, 7/50), and fruits (14%, 7/50). The most common drug triggers were antibiotics (59.4%, 22/37), non-steroidal anti-inflammatory drugs (NSAIDs) (10.8%, 4/37), vaccines (10.8%, 4/37), and herbal medicines (10.8%, 4/37). Common food allergens vary by age: milk and eggs for infants, fruit for children aged 1–2 years, and buckwheat for children older than 3 years. Ninety-eight cases (89.1%) had skin mucosal involvement, 78 (70.9%) had respiratory compromise, 45 (40.9%) had cardiovascular compromise, and 31 (28.2%) had gastrointestinal symptoms. Cardiovascular compromise and reduced level of consciousness were statistically different between the age groups (p < 0.05). Twenty cases (18.2%) had resolved spontaneously when they reached the hospital, 53 cases (48.1%) received epinephrine, 18 (16.4%) were hospitalized, and 2 (1.8%) experienced a biphasic reaction. Conclusions: Males are overrepresented in children with anaphylaxis, and food and drugs are common triggers in children. However, the types of common food triggers differ across age groups, and infants are more likely to have cardiovascular compromise and a reduced level of consciousness. However, the use of epinephrine remains inadequate. The training of clinical staff in recognizing anaphylaxis needs to be strengthened.

Residual tumor model in esophageal squamous cell carcinoma after neoadjuvant immunochemotherapy: Frequently involves the mucosa and/or submucosa.

The efficacy and safety of neoadjuvant immunochemotherapy (nICT) are widely explored in locally advanced esophageal squamous cell carcinoma (ESCC). Whether the "wait-and-see" strategy is applicable in ESCC after nICT is still lacking a theoretical basis. This study aimed to preliminarily explore the distribution of residual tumors and the regression pattern of ESCC after nICT. Patients undergoing radical esophagectomy after nICT in Fujian Medical University Union Hospital between January 2020 and March 2022 were identified. The resection specimens were re-evaluated by one experienced pathologist. The pathological response was assessed by tumor regression grade (TRG) (modified Ryan scheme). The TRG grade was divided into grades 0 (pathological complete response), 1, 2, and 3. The pathological stage was evaluated in the Eighth Edition AJCC. In the non-pCR group, the residual model was divided into four types: Type I, regression towards the lumen; type II, regression towards the invasive front; type III, concentric regression; and type IV, scattered regression. A total of 95 consecutive patients were included for analysis. Seventy-six (80.0%) of 95 patients were in non-pCR (pathological complete response), and nine patients (9/76, 11.84%) had isolated residual tumors in lymph nodes. There was no significant difference in baseline characteristics between the pCR group and the non-pCR group (p > 0.05). The overall distribution of TRG for all esophageal wall layers was TRG 0 = 28 (28/95, 29.5%), TRG 1 = 17 (17/95, 17.9%), TRG 2 = 18 (18.9%, 18/95), and TRG 3 = 32 (32/95, 33.7%). In 67 patients with residual tumors in the esophageal wall (TRG ≧1), 63 (63/67, 94.0%) had residual tumor cells in the mucosa and/or submucosa, and four had isolated residual tumors in the muscle layer (4/67, 6.0%). Further analysis showed eight (8/67, 11.9%) patients with submucosal involvement but without mucosal involvement. The distribution of regression patterns was type I (n = 35, 52.2%), type II (n = 3, 4.5%), type III (n = 8, 11.9%), and type IV (n = 21, 31.3%). The mucosa and/or submucosa are frequently involved in residual malignancy, and the frequent regression models are regression toward the lumen and random regression. There is an opportunity to carefully test the residual tumors in a subgroup of the population with ESCC following nICT. However, some patients had residual tumors only in the muscle layer or lymph nodes. The clinical application of the wait-and-see strategy in ESCC after nICT should be explored using an appropriate evaluation protocol.

Evolution of Bullous Pemphigoid Clinical Pattern over Time: A 17-Year Single-Centre Retrospective Survey of 312 Cases

Background and Objectives: Bullous pemphigoid (BP) clinical profile may have evolved during the last 2 decades. A retrospective, single-centre analysis investigated a possible shift of clinical presentation of the disease over time regarding both lesions’ clinical pattern and locations and more particularly an increased frequency of characteristics considered as less classical regarding the usual clinical description of BP. Patients and Methods: Initial clinical data from all BP patients treated between January 2001 and April 2017 in a reference centre were collected and compared between four 4-year successive chronological subsets (G1 to G4). Results: 213/312 patients retained for final analysis (68.3%) displayed at least one initial non-classical characteristic, mainly head and neck, palmo-plantar, and/or mucosal involvement. Chronological analysis confirmed a significant increase over time of the percentage of patients displaying such features (G1 57.9% vs. G4 73.7%, p = 0.041). Conclusion: Changes in BP clinical pattern may have occurred over the last two decades with the progressive emergence of forms with a number of less classical features. No significant clinical difference was observed between patients receiving or not DPP4 inhibitors at the time of diagnosis.

Monkeypox Infection With Primarily Mucosal Involvement.

Since May 2022, several nonendemic countries face a monkeypox outbreak, with clinic and epidemiological characteristics distinct from the classic ones. Primarily affecting the sexually active population, these cases present with mucocutaneous lesions mainly localized in perioral, genital, and anal areas. A retrospective study was conducted in a tertiary center in Lisbon, to characterize the population diagnosed with monkeypox infection with primarily mucosal involvement.

Rectal Bleeding Revealing Acute Myeloid Leukemia (AML): About a Case in the Hepato- Gastroenterolgy Department of National Hospital of Niamey

The hemorrhagic syndrome in its clinical, cutaneous and ocular diversity most often constitutes the circumstances in which acute leukemia is discovered. Digestive mucosal involvement is rarely indicative of serious bone marrow failure, thus posing a problem of etiological diagnosis in a gastroenterological medical setting [1]. In the literature, it varies from 2 to 10-15% depending on the study and is considered a sign of poor prognosis requiring early diagnosis for better management [2]. We report a case of a 59-year-old woman admitted for rectal bleeding associated with an anemic syndrome. The initial clinical examination showed a finger cot stained with bright red blood. The blood count had shown anemia at 6.4g/dl microcytic, normochromic, neutropenia at 1.8x103, thrombocytopenia at 36.103. Colonoscopy and esogastroduodenoscopy were normal. Blood smear and myelogram were in favor of Acute Myeloid Leukemia. Karyotype and immunophenotyping were not performed. Symptomatic treatment was offered. The evolution is marked by the improvement of the clinical signs. This association, acute myeloid leukemia and rectal bleeding is rarely described in the literature.

COVISHIELD Vaccine–Induced Ocular Stevens-Johnson Syndrome: A Case Report

Abstract: Stevens-Johnson syndrome (SJS) is an acute inflammatory vesiculobullous reaction of the skin and mucosa. The involvement of the ocular mucosa in these cases leads to ocular SJS. The most commonly reported etiological agents for SJS are drugs, viral infections, and vaccination. Here, we present the first ever reported case of ocular SJS occurring secondary to COVISHIELD vaccination, wherein a 62-year-old had an episode of acute SJS within a week of the COVISHIELD booster dose. She presented to us 6 months after the acute episode with infectious keratitis in the right eye and descemetocele in the left eye in chronic SJS with severe bilateral lid keratinization in all 4 lids and healed skin pigmentation typical of SJS sequelae.

Airway management in a patient with Stevens-Johnson syndrome/toxic epidermal necrolysis: a case report

Stevens-Johnson syndrome (SJS), of which toxic epidermal necrolysis (TEN) is a more severe variant, is a cutaneous hypersensitivity reaction, usually triggered by certain prescribed medications. Airway management in SJS/TEN poses significant challenges, particularly when there is facial skin and oropharyngeal mucosal and/or laryngeal involvement. There is limited literature guiding definitive airway management in patients with severe SJS/TEN. We describe a case utilizing transnasal humidified rapid insufflation ventilatory exchange (THRIVE) to preoxygenate and maintain apneic oxygenation as a means of avoiding facemask ventilation and excessive airway instrumentation in a patient with SJS/TEN involving the face and oral mucosa. This case report demonstrates the use of THRIVE as a tool to optimize oxygenation and safe airway management in situations where conventional approaches may be challenging.

Monkeypox virus infection in women and non-binary people: uncommon or neglected?

Monkeypox virus infection in women and non-binary people: uncommon or neglected?

Catastrophic presentation of pemphigus vulgaris with Norwegian scabies in a patient with HIV

A 40-year-old female, previously healthy, started 2 months earlier with skin lesions (Figure 1A) characterized by blisters of 3 to 4 cm on the trunk and extremities that, when broken, left denuded areas, excoriations, and painful and pruritic meliceric crusts with serohematic secretion: with involvement of the gingival mucosa, palate, and oropharynx. Biopsy is performed (Figure 1B) showing intraepidermal acanthosis in the lower portions of the epidermis and spongiosis with exocytosis of neutrophils, perivascular infiltrate with eosinophils in the dermis. Human Immunodeficiency Virus (HIV) positive is reported by Elisa. At the respiratory level, he progressed with respiratory acidosis, for which a chest X-ray was taken (Figure 1C) with an increase in the parahilar pattern, with no evidence of a pneumonic process.

Mortality risk factors in febrile ulceronecrotic Mucha- Habermann disease: A systematic review of therapeutic outcomes and complications.

Febrile Ulceronecrotic Mucha- Habermann Disease (FUMHD) is a variant of Pityriasis Lichenoides Et Varioliformis Acuta (PLEVA). Although rare, the condition may progress to involve serious complications and even lead to fatal outcomes if diagnosis and appropriate treatment is delayed. A PubMed search following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIMSA) guidelines was performed to find cases of FUMHD from the earliest records to October 2021. Treatments, complications, and patient outcomes were extracted from the literature and summarized, while a review of quality was also performed. A total of 63 publications with 68 patients were found. Successful treatment modalities for FUMHD included antibiotics, antivirals, systemic steroids, Methotrexate (MTX), cyclophosphamide, Cyclosporine (CYA), Intravenous Immunoglobulins (IVIG), pentoxifylline, and ultraviolet B phototherapy. Out of 68 patients, 55 patients had their condition fully resolved and 13 cases were fatal. Increased age, systemic involvement, and monoclonal T-cell receptor rearrangement were associated with worst prognosis, but mucosal involvement did not affect mortality risk. Overall, the publications had low risk of bias, but most lacked adequate follow-up periods. FUMHD is a diagnostic and therapeutic challenge due to the lack of clearly defined diagnostic criteria and optimum treatment. Further studies with larger patient populations and longer follow-up periods may lead to refinement of diagnostic criteria, establish an optimum treatment regimen, and better estimate the likelihood of recurrence.

Human monkeypox virus infection in women and non-binary individuals during the 2022 outbreaks: a global case series

Between May and November, 2022, global outbreaks of human monkeypox virus infection have been reported in more than 78 000 people worldwide, predominantly in men who have sex with men. We describe the epidemiological and clinical characteristics of monkeypox virus infection in cisgender (cis) and transgender (trans) women and non-binary individuals assigned female sex at birth to improve identification and understanding of risk factors. International collaborators in geographical locations with high numbers of diagnoses of monkeypox virus infection were approached and invited to contribute data on women and non-binary individuals with confirmed monkeypox virus infection. Contributing centres completed deidentified structured case-report spreadsheets, adapted and developed by participating clinicians, to include variables of interest relevant to women and non-binary individuals assigned female at birth. We describe the epidemiology and clinical course observed in the reported infections. Collaborators reported data for a total of 136 individuals with monkeypox virus infection who presented between May 11 and Oct 4, 2022, across 15 countries. Overall median age was 34 years (IQR 28-40; range 19-84). The cohort comprised 62 trans women, 69 cis women, and five non-binary individuals (who were, because of small numbers, grouped with cis women to form a category of people assigned female at birth for the purpose of comparison). 121 (89%) of 136 individuals reported sex with men. 37 (27%) of all individuals were living with HIV, with a higher proportion among trans women (31 [50%] of 62) than among cis women and non-binary individuals (six [8%] of 74). Sexual transmission was suspected in 55 (89%) trans women (with the remainder having an unknown route of transmission) and 45 (61%) cis women and non-binary individuals; non-sexual routes of transmission (including household and occupational exposures) were reported only in cis women and non-binary individuals. 25 (34%) of 74 cis women and non-binary individuals submitted to the case series were initially misdiagnosed. Overall, among individuals with available data, rash was described in 124 (93%) of 134 individuals and described as anogenital in 95 (74%) of 129 and as vesiculopustular in 105 (87%) of 121. Median number of lesions was ten (IQR 5-24; range 1-200). Mucosal lesions involving the vagina, anus, or oropharynx or eye occurred in 65 (55%) of 119 individuals with available data. Vaginal and anal sex were associated with lesions at those sites. Monkeypox virus DNA was detected by PCR from vaginal swab samples in all 14 samples tested. 17 (13%) individuals were hospitalised, predominantly for bacterial superinfection of lesions and pain management. 33 (24%) individuals were treated with tecovirimat and six (4%) received post-exposure vaccinations. No deaths were reported. The clinical features of monkeypox in women and non-binary individuals were similar to those described in men, including the presence of anal and genital lesions with prominent mucosal involvement. Anatomically, anogenital lesions were reflective of sexual practices: vulvovaginal lesions predominated in cis women and non-binary individuals and anorectal features predominated in trans women. The prevalence of HIV co-infection in the cohort was high. None.

Efficiency and Toxicity of Imatinib Mesylate Combined with Atorvastatin Calcium for Steroid-Refractory Chronic Graft-Versus-Host Disease

Background: Chronic graft-versus-host disease (cGVHD) represents the most common long-term complication associated with allogeneic hematopoietic stem cell transplantation. Moreover, steroid-refractory cGVHD (SR-cGVHD) presents new challenges for treatment. Currently, while imatinib and statins drugs have been recognized to regulate T cell function, their effects and mechanism in combined treatment for cGVHD remain unknown. Methods: A total of 60 SR-cGVHD patients were entered into a clinical single-arm trial investigating the combination of imatinib mesylate and atorvastatin calcium for the treatment of SR-cGVHD. The efficacy, safety, and immune effects were evaluated after treatment using the 2014 NIH scoring system and changes in T cell subclones. The primary end points consisted of the overall response rate (ORR) after 6 months of treatment with imatinib mesylate and atorvastatin calcium, which were evaluated according to the NIH criteria. The secondary end point consisted of an evaluation of survival, the changes of T cell subsets and adverse events. Results: At baseline, 45% (27/60) of the patients had moderate cGVHD and 55.0% (33/60) patients had severe cGVHD. There were 32 (53.3%) patients with skin involvement, 31 (51.7%) patients with liver involvement, and 21 (35.0%) with clinical lung involvement, with compromised forced expiratory volume and/or diffusion capacity of the lung for carbon monoxide. There were 23 (38.3%) patients who exhibited oral mucosal involvement, 12 (20.0%) with joint and fascia involvement and 11 (18.3%) who exhibited gastrointestinal tract involvement, eyes 13 (21.7%), genitalia 2 (3.3%). The median follow up was 17 (4-25) months. At the 6 months follow-up, 70.0% of the patients achieved a clinical response, Complete response (CR) was achieved in 26.7% of the patients. After 6 months of treatment, the ORR rate of the liver, skin, eyes and oral cavity was 80.6%, 78.1%, 61.5%, and 60.9%, respectively, the liver was also the organ that achieved the highest CR of 58.1%. The cumulative overall survival rate, relapse and NRM for all treated patients was 78.9%, 15.5% and 11.7% (Fig A-C). Patients who achieved CR and PR showed a better survival outcomes (P= 0.0106) (Fig D). There was a decreased proportion of Th17 cells (P = 0.0171), whereas there was an increase in Treg cells (P = 0.0147) after 3 months in the clinical response patients. No toxic deaths were observed in this study, The main adverse was edema (13.3%) and nausea (10%). Conclusion: Imatinib mesylate and atorvastatin calcium combination treatment was effective for treating SR-cGVHD and significantly induced improvement in target organ injury, especially in the liver. T cell regulation may play an important role in this process.

Profil épidémiologique des toxidermies à Dakar : Etude de 200 cas

Background: Previous studies in Africa have shown severity of toxidermia with a risk of mortality and mucosal synechia. Our objective was to study the epidemiological, clinical, etiological and evolutionary aspects of toxidermia in Dakar. Methods: A cross-sectional retrospective study was conducted at the Department of Dermatology of the Hospital Le Dantec from January 2001 to December 2015. She identified all of the toxidermia cases of hospitalization in this department. The diagnosis was based on the French criteria for drug accountability. Results: Two hundred cases of toxidermia were recorded. The hospital frequency was 9.2%. The sex ratio was 0.61. The average age was 33 years. Clinical forms of bullous toxidermia were Stevens Johnson/Lyell in 54% (n = 108), erythema multiforme in 3% (n = 6), and fixed pigmented erythema in 2% (n = 4). Mucosal involvement was noted in 56.5% (n = 113). Visceral involvement was noted in 15% (n = 30) with respiratory involvement in 24 cases of SSJ/NET and 6 cases of DRESS. The drugs identified were antibiotics in 38,7% (n = 53), analgesics in 15,3% (n = 21), anti-comitials in 13,1% (n = 18), antiretrovirals in 11,7% (n= 16), antituberculosis drugs in 9,5%% (n = 13) and medicinal plants in 11,7% (n = 16). The outcome was favorable in 62.5% (n = 125). Death was noted in 12%. Conclusion: Toxidemia in Dakar are characterized by predominance in severe clinical forms in young adults and mortality was related to infectious and hydro electrolyte complications.

MRNA COVID-19 VACCINE-ASSOCIATED BULLOUS FIXED DRUG ERUPTION

<h3>Introduction</h3> Fixed drug eruptions are unique cutaneous drug reactions that recur in the same location upon re-exposure to the offending agent. We report a dilemma of how to proceed with the vaccination after a rare complication of the mRNA covid-19 vaccine. <h3>Case Description</h3> A 47-year-old female referred to us after developing a rash to the mRNA covid-19 vaccine for evaluation of safety and plan on how to proceed with the booster vaccine. After the 1^st dose on her left deltoid, she developed persistent right arm pruritus from mid-forearm to wrist that gradually became well-demarcated and erythematous by day four. Rash improved within seven days of using hydrocortisone but left hyperpigmentation of the skin. Two weeks after receiving her 2^nd dose on her left deltoid, the same location on her right forearm flared up with more pronounced pruritus, erythema and a few bullous lesions. Rash improved after a week of using hydrocortisone leaving behind hyperpigmentation. The patient denied using any prior medications and had no other skin or mucosal involvement. We decided to proceed with another brand of mRNA covid-19 vaccine instead and prophylactically apply clobetasol twice daily to the affected area for 7-days post-vaccine. She tolerated the vaccine without any flare-up of the rash. <h3>Discussion</h3> Fixed drug eruptions more frequently occur with drugs including antimicrobials, NSAIDs, acetaminophen and anti-convulsants. Very rarely has it been reported in association with the administration of the Covid-19 vaccines. This case illustrates a unique predicament after an unusual complication of bullous fixed drug eruption after mRNA covid-19 vaccine administration.

S2k Guideline for the diagnosis and treatment of mucous membrane pemphigoid.

Mucous membrane pemphigoid (MMP) is a pemphigoid disease with predominant mucous membrane involvement. It mainly affects the mucous membranes of the mouth, eyes, nose and pharynx, but also the larynx, trachea, esophagus, genital and perianal regions. The manifestation of the disease covers a wide spectrum from gingival erythema and single oral lesions to severe tracheal strictures that obstruct breathing and conjunctival scarring with marked visual impairment and, not infrequently, blindness. In addition to a clinical picture of predominant mucosal involvement, diagnosis is based on direct immunofluorescence of a peri-lesional biopsy and serology. The main target antigen is BP180 (collagen XVII), and reactivity with laminin 332 is associated with malignancy in approximately 25% of MMP patients. The treatment of MMP is challenging. On the one hand, due to the involvement of different mucous membranes, good interdisciplinary cooperation is required; on the other hand, due to the rarity of the disease, no randomized controlled clinical trials are available. The aim of this guideline is to present the clinical picture, including severity and scoring systems, and to give guidance for diagnosing and treating this complex disease. In MMP, interdisciplinary cooperation plays an essential role as well as the prompt diagnosis and initiation of adequate therapy in order to avoid irreversible damage to the mucous membranes with serious complications.

PSUN62 A Rare Case of Atorvastatin Induced Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome - A Case Report.

Abstract Clinical Case A 77 year-old female presented to emergency department with progressively worsening rash that started one week ago. On physical examination blanching erythema was noted in lower back, buttocks and extremities. There was no desquamation or involvement of oral mucosa. No lymphadenopathy or hepatosplenomegaly was noted. Laboratory investigations showed white blood cell count of 21.2×10^3/uL, with 33.1% eosinophils. Creatinine was elevated at 2.8mg/dL from baseline of 0.8mg/dL. Further lab work revealed alkaline phosphate 2314 IU/L, aspartate transaminase 587 IU/L, and alanine transaminase 620 U/L, total bilirubin 7.3mg/dL with direct bilirubin of 5.1mg/dL, Immunoglobulin E level of 2000 IU/ml and normal Tryptase levels. Serology for viral hepatitis, Epstein-Barr virus, Cytomegalovirus and Human immunodeficiency virus was negative. Autoimmune workup including antinuclear Antibody (ANA), anti-neutrophil cytoplasmic antibody (ANCA), mitochondrial antibody, smooth muscle antibody, double stranded DNA, anti-histone antibody, rheumatoid factor, Sjogren's antibody and centromere antibody were negative. Urinalysis, urine protein electrophoresis and serum protein electrophoresis were also normal. Computed tomography (CT) scan of chest showed mild supraclavicular and mediastinal lymphadenopathy. Review of medical records revealed that patient was recently discharged from hospital with a prescription of Atorvastatin following admission for transient ischemic attack 6 weeks ago. Skin biopsy showed superficial perivascular dermatitis with extravasation of red blood cells with no diagnostic evidence of vasculitis, granuloma or malignancy. Based on biopsy findings, recent drug administration followed by appearance of rash, hematological abnormality, lymphadenopathy and multi-system involvement and after exclusion of other possible causes, diagnosis of DRESS syndrome was made. Atorvastatin was held and patient was given Methylprednisolone for three days followed by Prednisone 1mg/kg with taper. Rash as well as kidney and liver functions improved drastically within two days. Discussion Our patient presented with one week of rash associated with deteriorating kidney and liver functions. Atorvastatin was initiated five weeks prior to development of rash. All the possible infectious etiologies and malignancy was ruled out based on the laboratory work mentioned above. Work up for vasculitis was also negative. DRESS syndrome is a late onset drug induced hypersensitivity reaction which usually manifests 3 weeks to months after the offending drug is started. It is very rare with an incidence of 0.9-2 per 100,000 patients per year and accounts for 10-20% of all cutaneous adverse drug reactions. DRESS syndrome if untreated carries significant risk of mortality, between 10-20%. RegiSCAR (European Registry of Severe Cutaneous Adverse Reaction) scoring system can be used to help diagnose DRESS syndrome. It takes into account multiple factors including fever, lymphadenopathy, eosinophilia, rash, number of organs involved, disease duration, skin biopsy findings and negative results of investigations to rule out alternate causes of patient's symptoms. Patient responded well to systemic steroids followed by oral steroids with taper. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Histopathological Features of Helicobacter pylori Infection in Gastric Mucosa.

To investigate the histopathological characteristics of Helicobacter pylori (Hp) infection in the gastric mucosa in the process from occurrence to intraepithelial neoplasia. Specimens obtained from the endoscopic biopsy and endoscopic submucosal dissection of 2457 cases of gastric Hp infection were observed and assessed in detail using histology and immunohistochemistry techniques. The condition was divided according to the histopathological characteristics of gastric mucosal damage caused by Hp infection. The histopathological characteristics and immunophenotype of each stage were subsequently elucidated. Helicobacter pylori is initially implanted in the mucus layer covered by the epithelium on the surface of the gastric mucosa. It then selectively adheres to the cytoplasm of the surface mucus cells, which makes the oval and spherical particles containing mucus that is wrapped by the bounded membrane in the cytoplasm on the nucleus of the surface mucus cells disappear, while the cytoplasm undergoes spiderweb-like vacuolar degeneration. This leads to the proliferation and transformation of the surface mucous cells before developing into intraepithelial neoplasia. In the process of histomorphology, mucosal ulcers, mucosal lymphoid tissue proliferation, gland atrophy, intestinal epithelial metaplasia, mucosa-associated lymphoid tissue lymphoma, and adenocarcinoma may occur. In this study, the condition was divided into five stages according to the histopathological characteristics of gastric mucosal damage caused by Hp infection, as well as the degree of gastric mucosal damage and involvement depth as follows: the mucus infection stage, the surface epithelial cell infection stage, the lamina propria lesion stage, the mucosal atrophy stage, and the intraepithelial neoplasia stage. Understanding the histopathological characteristics of gastric Hp infection in terms of its occurrence and development into intraepithelial neoplasia is conducive to the precise treatment and tracking of malignant cell transformation, and is of great significance in controlling the occurrence and development of gastric cancer.