Rare Extrapulmonary Manifestation Research Articles

Acute pancreatitis as a complication of acute COVID-19 in kidney transplant recipients.

Acute pancreatitis is a rare extrapulmonary manifestation of coronavirus disease 2019 (COVID-19) but its full correlation with COVID-19 infection remains unknown. To identify acute pancreatitis' occurrence, clinical presentation and outcomes in a cohort of kidney transplant recipients with acute COVID-19. A retrospective observational single-centre cohort study from a transplant centre in Croatia for all adult renal transplant recipients with a functioning kidney allograft between March 2020 and August 2022 to record cases of acute pancreatitis during acute COVID-19. Data were obtained from hospital electronic medical records. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was proven by a positive SARS-CoV-2 real-time reverse transcriptase-polymerase chain reaction on the nasopharyngeal swab. Four hundred and eight out of 1432 (28.49%) patients who received a renal allograft developed COVID-19 disease. The analyzed cohort included 321 patients (57% males). One hundred and fifty patients (46.7%) received at least one dose of the anti-SARS-CoV-2 vaccine before the infection. One hundred twenty-five (39.1%) patients required hospitalization, 141 (44.1%) developed pneumonia and four patients (1.3%) required mechanical ventilation. Treatment included immunosuppression modification in 233 patients (77.1%) and remdesivir in 53 patients (16.6%), besides the other supportive measures. In the study cohort, only one transplant recipient (0.3%) developed acute pancreatitis during acute COVID-19, presenting with abdominal pain and significantly elevated pancreatic enzymes. She survived without complications with a stable kidney allograft function. Although rare, acute pancreatitis may complicate the course of acute COVID-19 in kidney transplant recipients. The mechanism of injury to the pancreas and its correlation with the severity of the COVID-19 infection in kidney transplant recipients warrants further research.

Рабдомиолиз — редкое внелегочное проявление внебольничной пневмонии, вызванной Mycoplasma pneumonia

Aim. To present a clinical case of a 19-year-old patient with community-acquired pneumonia (CAP) caused by Mycoplasma pneumoniae, which was complicated by a rare extrapulmonary manifestation in the form of rhabdomyolysis. Key points. The clinical case demonstrates a variant of mycoplasma CAP in an adult patient. M. pneumoniae infection was confirmed by a positive PCR test. Characteristic is contact with a patient with mycoplasma CAP in an infectious focus, a flu-like onset of the disease. Unlike most mild mycoplasma infections with a minimally expressed clinical picture and inflammatory response, the patient had a long period of febrile temperature and severe intoxication, significant laboratory changes and bilateral polysegmental lung damage. The development of signs of rhabdomyolysis (myalgia, increased creatine phosphokinase (CPK) to 2066 U/L, myoglobinuria) in the acute period of the disease is a rare extrapulmonary manifestation of mycoplasma CAP in adults, dangerous for the development of acute renal failure (ARF). Conclusion. The patient's young age, timely initiation of hydration, and antibacterial therapy aimed at M. pneumoniae made it possible to prevent the development of acute renal failure due to rhabdomyolysis. An increase in CPK, in the absence of other explanations for this phenomenon, should include mycoplasma CAP in the differential diagnosis of rhabdomyolysis. Keywords: community-acquired pneumonia, Mycoplasma pneumoniae, creatine phosphokinase, rhabdomyolysis.

Primary Parotid Tuberculosis in a Toddler

Tuberculosis (TB) of the parotid gland is a rare disease and occurs less frequently in children. Re-emergence is seen amongst immunocompromised individuals whose diagnosis may be overlooked, leading to unnecessary surgery. Diagnosis is challenging in the absence of systemic constitutional symptoms and depends mainly on the treating physician having a strong suspicion. We report a rare extrapulmonary manifestation of TB involving the parotid gland in an otherwise immunocompetent child. A 2-year-old girl presented with a mass in the right parotid region that had been present for 3 months. A similar swelling was treated with an antibiotic 3 months prior, but it recurred. The mass was painful, firm, erythematous, and located in the infra-auricular region. Symptoms persisted after 2 courses of antibiotics, after which ultrasonography was performed and the intra-parotid collection was aspirated, which was positive for acid-fast bacilli (AFB). The patient was placed on anti-TB treatments. Although uncommon, TB should be considered in patients with a solitary mass in the parotid gland to avoid unnecessary surgery.

Mycoplasma pneumoniae-induced rash and mucositis: A rare extrapulmonary manifestation of mycoplasma pneumoniae infection

Mycoplasma pneumoniae (M. pneumoniae) is a common atypical pathogen in humans, causing community-acquired pneumonia. Isolated Mycoplasma pneumoniae cases are commonly seen in the community, but an extrapulmonary manifestation like severe mucositis without skin lesions is rarely seen. The Mycoplasma-Induced Rash and Mucositis (MIRM) or Mycoplasma Pneumoniae-Associated Mucositis (MPAM) is a severe manifestation of an atypical organism. Still, morbidity and mortality are less than Mycoplasma-Associated Steven Johnson’s Syndrome (MASJS) and Toxic Epidermal Necrolysis (TEN). We reported a case of a young adult admitted with pneumonia and rapidly developed severe mucositis without skin manifestations, which has increased his morbidity and recovery time.

383: MYOCARDITIS DUE TO LEGIONELLA: A CASE REPORT

Introduction: Legionnaires’ disease is pneumonia caused due to Legionella species. Among the rare extrapulmonary manifestations, cardiac involvement is most prevalent in myocarditis, pericarditis, post-cardiotomy syndrome, and prosthetic valve endocarditis. The morbidity and mortality associated with such an uncommon presentation of legionella myocarditis are quite high. We describe a rare case of Legionella myocarditis in a 35-year-old female associated with acute left ventricular dysfunction with sepsis and pneumonitis. Description: The patient presented with fever, headache, giddiness, chills, myalgias, generalized body aches, altered mental sensorium, acute onset dyspnea, hypoxemia (83%), low blood pressure (86/56 mm Hg), respiratory failure, renal failure, and ischemic hepatic injury. She was intubated and stabilized with multiple inotropes. Echocardiography (Echo) showed borderline increase in cardiac chambers with severe, and mild mitral regurgitation (MR), mild tricuspid regurgitation (TR). The estimated LV ejection fraction (LVEF) was 10-15% with grade III LV diastolic dysfunction. X-ray showed haziness in the right lower zone with blunting of the right CP angle. She was admitted in the intensive care unit for 8 days. Due to significantly raised cardiac biomarkers (Troponin), borderline dilated chambers, and severe LV dysfunction on echocardiogram, a provisional diagnosis of fulminant myocarditis was made. Legionella infection was diagnosed on the basis of a serum pneumoslide IgM test. Although the result from the biopsy would have strengthened the diagnosis, but it was too risky. After appropriate medication, the patient improved significantly and transferred to the floor. After 10 days of monitoring, the patient was discharged and was advised follow-up after 1 week. She recovered fully and follow-up echocardiography showed marked improvement in the cardiac function. Echo Images will be presented during poster presentation. Discussion: A high degree of clinical suspicion and a thorough history is needed to suspect legionella infection. The prognosis of Legionella myocarditis depends on systemic involvement, comorbidities, and the delay before beginning directed therapy.

LEGIONNAIRES DISEASE: A CASE WITH SEVERE NEUROLOGIC AND RENAL INVOLVEMENT

LEGIONNAIRES DISEASE: A CASE WITH SEVERE NEUROLOGIC AND RENAL INVOLVEMENT

Adolesan Bir Hastada Granülomatöz Üveit ile Seyreden Oküler Tüberküloz: Nadir Bir Olgu Sunumu

Tuberculosis continues to be a significant global public health issue. Tuberculosis most often affects the lungs. However, children are more likely to have extrapulmonary involvement compared to adults. Ocular involvement is a rare extrapulmonary manifestation of tuberculosis. Ocular tuberculosis may affect any part of the eye and can be remain unnoticed due to the lack of clinically evident symptoms or findings, if there is no history of tuberculosis contact or other systemic signs or if these are not questioned. Here, we present an adolescent case who was diagnosed with pulmonary and ocular tuberculosis when investigating the underlying cause of granulomatous uveitis and successfully controlled with four drug regimen anti-tuberculosis and methylprednisolone treatment. In conclusion, ocular tuberculosis is an important cause of ocular morbidity. Diagnosis and follow-up require a multidisciplinary approach.

Covid-19 associated shoulder girdle calcific myositis: a novel entity.

To investigate the prevalence, describe the radiological features, and consider the clinical sequelae of COVID-19- associated shoulder girdle calcific myositis. All patients who underwent a CT pulmonary angiogram study at our institution (Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, United Kingdom) in April and May 2020, January 2021, and July 2021 were included. A total of 1239 CT pulmonary angiogram studies for 1201 patients were reviewed. Patients with COVID-19 and associated shoulder girdle calcific myositis were identified. Their electronic patient records were reviewed. The patients' demographics, serum inflammatory markers, and proning history were recorded. Of the 364 patients in Wave 1, 71 patients (19.5%) had COVID-19, and of those, 2 patients (2.8%) had shoulder girdle calcific myositis. Of the 521 patients in Wave 2, 354 patients (67.9%) had COVID-19, and of those, 3 patients (0.8%) had shoulder girdle calcific myositis. Of the 316 patients in Wave 3, 37 patients (11.7%) had COVID-19, and of those, 1 patient (2.7%) had shoulder girdle calcific myositis. The overall prevalence was 1.3%. The most common site of calcific myositis was within the subscapularis muscle. COVID-19-associated shoulder girdle calcific myositis is a rare extrapulmonary musculoskeletal manifestation of COVID-19. Early recognition and increased awareness of this disease entity, in our experience, aids in reducing patient morbidity and improving long-term functional outcome. We have reported a novel disease entity associated with COVID-19, in the form of shoulder girdle calcific myositis. We have described the common imaging features and discussed our experience of management and clinical sequelae.

Spontaneous intestinal perforation in critical COVID: A case report

Spontaneous intestinal perforation is a rare extrapulmonary manifestations of critical COVID-19 case. The pathogenesis of viral etiology is still unclear and association to some essential therapeutic treatment such as steroid or interleukin-9 antagonist is also inconclusive. Surgery is not mandatory If source control and sepsis can be accomplished with available interventions reported in current literatures. This uncommon complication develops either at time of presentation or after hospital admission, both upper and lower gastrointestinal tract1 We reported an ARDS patient experienced cardiac thrombus without valvular defect or arrhythmia who was diagnosed of spontaneous intestinal perforation from acute necrotizing ileitis necessitated damage control surgery.

Skeletal Infections Caused by Coccidioides Species.

Background: Coccidioidomycosis represents an endemic and challenging disease, with rare extrapulmonary manifestations. The present review of all published cases of core and extremities osseous coccidioidomycosis aims to describe epidemiology, patients’ characteristics, symptoms as well as medical and surgical treatment options and their effectiveness. Methods: A thorough review of all published skeletal core and extremity infections due to Coccidioides species was conducted. Information regarding demographics, causative fungus, antifungal treatment (AFT), surgical management as well as the infection outcome was recorded. Results: A total of 92 cases of Coccidioides spp. skeletal infections were recorded in 87 patients. The patients’ mean age was 35.3 years. The most common site of infection was the spine (82.6%), followed by the foot (6.5%), while the predominant symptom upon presentation was pain (29.9%). Immunosuppressive conditions and/or medications were observed in 21 patients (24.1%). Regarding imaging methods, indicating diagnosis, plain X-rays or CT scans were performed in most patients (50.6%), followed by magnetic resonance imaging (MRI) (47.1%). Most cases were diagnosed through histopathology (62; 71.3%), followed by serology testing (36; 42.4%) and by cultures (35; 40.2%). In 32 cases (36.8%), Coccidioides immitis was cultured, while in the remaining 55 cases (63.2%) the fungus was not further characterized. Regarding AFT, amphotericin B was the preferred agent (52.9%), followed by fluconazole (43.3%). In most cases (78.2%) surgical treatment was also performed. Treatment was successful in 80.5% of cases. Conclusions: Skeletal core and extremity infections due to Coccidioides spp. represent a severe disease. With the available data, the combination of prolonged proper AFT with surgical intervention seems to be the optimal current therapeutic approach.

Clinical Profile of Patients with Tuberculous Arthritis Admitted in a Tertiary Hospital in the Philippines

Background. Tuberculous arthritis is a rare extra-pulmonary manifestation of tuberculosis (TB) that can lead to significant disability when left untreated. This study described the clinical profile of patients with TB arthritis admitted in a tertiary hospital in the Philippines.
 Methods. We reviewed medical records of 65 patients with TB arthritis admitted in the Philippine General Hospital from 2006 to 2019.
 Results. Majority of patients were male (41, 63.0%) and the mean age upon diagnosis was 46.7 ± 1.7 years (20– 85). Majority (33, 50.8%) had underlying co-morbidities including hypertension (16, 24.6%), type 2 diabetes mellitus (10, 15.4%), and chronic kidney disease (8, 12.3%). A history of previous TB treatment (10, 15.4%), intake of immunosuppressive drugs (7, 10.8%), and trauma on affected joints (13, 20.0%) were also reported. Majority presented with chronic mono-arthritis (50, 76.9%) involving the knees (27, 41.5%) and hips (21, 32.3%) with a mean duration of symptoms of 20.9 ± 3.9 months. The most frequent initial diagnosis upon admission was septic arthritis (21, 32.3%). Confirmed septic arthritis (10, 15.6%), pulmonary TB (9, 14.3%), and disseminated TB (4, 6.3%) were also observed. Majority were diagnosed based on positive acid-fast bacilli (AFB) smear, polymerase chain reaction (PCR) for Mycobacterium tuberculosis, or synovium biopsy (34, 54.0%). Anemia (43, 68.3%) and elevated inflammatory biomarkers (erythrocyte sedimentation rate, ESR [36, 97.3%] and C-reactive protein, CRP [40, 87%]) were also seen in majority of patients. The most common radiographic findings on x-ray were joint space narrowing (42, 84.0%), soft tissue swelling (22, 44.0%), and erosions (21, 42.0%). The mean length of hospital stay was 23.8 ± 2.8 days (2–113). Majority underwent surgical interventions (35, 55.6%) including debridement (28, 80.0%) and arthrotomy (25, 71.4%). All received anti-tuberculosis treatment upon diagnosis.
 Conclusion. Majority of patients with TB arthritis in this study were male, with mean age in the 5th decade of life, presenting with mono-arthritis, anemia, elevated inflammatory markers, and radiologic findings of joint narrowing. All patients received medical treatment while more than half underwent surgery. There should be a high index of suspicion for TB arthritis in a patient from an endemic country presenting with chronic mono arthritis in weight-bearing joints to prevent delay in diagnosis and significant joint destruction and disability

Pure red cell aplasia secondary to rheumatoid arthritis: a case report

BackgroundRheumatoid arthritis is a common autoimmune disease with many extra-articular manifestations. Pure red cell aplasia is a rare manifestation of rheumatoid arthritis and is sparsely documented in the literature, with a variable clinical outcome following immunosuppressive therapy.Case presentationA 63-year-old Sinhalese female presented with transfusion-dependent anemia associated with deforming inflammatory arthritis. She also had leukopenia, right subclavian venous thrombosis, and generalized lymphadenopathy. The diagnosis of rheumatoid arthritis following initial clinical workup and additional blood and bone marrow investigations revealed pure red cell aplasia as a secondary manifestation of rheumatoid arthritis after excluding other secondary causes, such as infections, thymoma, thrombophilic conditions, and hematological malignancy. She responded well to oral prednisolone, cyclosporine A, and hydroxychloroquine, and she attained complete recovery in 2 months.ConclusionPure red cell aplasia is a disabling illness that may lead to transfusion-dependent anemia, which may occur due to rare extrapulmonary manifestation of rheumatoid arthritis. The diagnosis of pure red cell aplasia secondary to rheumatoid arthritis may be challenging where hematological investigations, including bone marrow biopsy, will aid in the diagnosis, and early diagnosis and treatment will bring about a better outcome.

Answer to October 2021 Photo Quiz.

We report an unusual pyomyositis with concomitant pulmonary lesions in an HIV-positive patient. Due to the difficulty of collecting sputum, gastric lavage was performed. The abscess in the leg was drained (Fig. 1B in photo quiz case presentation). The gastric lavage and the abscess drainage were analyzed using an acid-fast bacilli smear (Fig. 1C in photo quiz case presentation) and Xpert MTB/RIF assay. Gastric lavage, purulent drainage, and blood culture were positive for Mycobacterium tuberculosis. The typical formation of serpentine cords was demonstrated upon culture of abscess drainage (Fig. 1D in photo quiz case presentation). Gastric lavage was M. tuberculosis nucleic acid positive by Xpert MTB/RIF assay. The diagnosis of tuberculosis (TB) pyomyositis was confirmed. Anti-TB therapy (rifampin) was started. Pyomyositis is the accumulation of purulent material within individual muscle groups, and the most common organisms implicated in pyomyositis include Staphylococcus aureus (1). Typical cases of pyomyositis involve fever and pain, which are specific to a muscle group, generally the lower extremities (1, 2). TB pyomyositis, defined as M. tuberculosis infection of skeletal muscle, is more common in immunocompromised patients, but even in these patients, it is considered to be a rare extrapulmonary manifestation of TB. The clinical manifestations may be insidious, with nonspecific symptoms, such as fever, night sweats, malaise, and weight loss (3). Ohnishi et al. reported three cases of TB pyomyositis in women coinfected with TB/HIV with a CD4 below 200 cells/mm3 (4). Pathogenesis for TB pyomyositis can include contiguous spread, lymphatic or hematogenous spread, and direct inoculation (3, 5). We hypothesize that in this case it was a hematogenous spread because of the absence of trauma or infection, with no evidence of osteomyelitis. TB pyomyositis is very difficult to clinically diagnose and distinguish from other soft tissue diseases. Diagnosis depends on a high clinical suspicion of infection in a susceptible population. TB should be considered in patients who present with soft tissue swelling and pain, particularly if they have an abnormal chest X-ray (6). Drainage through surgery and aggressive anti-TB therapy is normally required (7). The case presented here is noteworthy given the rarity of this manifestation of TB and highlights the need for early diagnosis. With timely diagnosis and adequate clinical and surgical treatment, the prognosis is good. Prompt diagnosis requires a high index of suspicion, especially in immunocompromised patients. Fluid cultures should be sent for acid-fast bacilli staining (Fig. 1C in photo quiz case presentation) and culture (8). In laboratories serving areas of high M. tuberculosis incidence with limited economic resources, cord factor detection (Fig. 1D in photo quiz case presentation) is a fast and valid criterion for identifying these mycobacteria using liquid or solid medium (9).

Sarcoidosis with Rare Extrapulmonary Involvement.

Sarcoidosis is a multisystemic granulomatous disease in which medullary involvement is a rare extrapulmonary manifestation.Bone marrow biopsy is rarely performed based on serial blood counts, which may be associated with underdiagnosis.FDG-PET cannot reliably distinguish between sarcoidosis and lymphoproliferative disease as the cause of extensive ganglion, splenic and bone marrow involvement, and so a high index of clinical suspicion is required.

511 A Case Report of A 16-Year-Old Girl with Peritoneal Tuberculosis

Abstract Peritoneal Tuberculosis (PTB) is a rare extra-pulmonary manifestation of Mycobacterium tuberculosis infection. It usually presents with non-specific symptoms that can mimic other intra-abdominal pathology. Therefore, a high index of suspicion is needed for diagnosis and early treatment of PTB. Some of the intra-abdominal conditions in young patients that may have similar presentations to PTB include Crohns’ disease, ovarian pathology and acute appendicitis. Diagnosing PTB in the paediatric population tends to be even more challenging as an obvious history of exposure may be difficult to obtain. Diagnostic laparoscopic biopsy and histopathology provides definitive diagnosis. Most studies recommend a 6-month course of anti-TB therapy for abdominal tuberculosis with a planned regimen using Isoniazid, Rifampicin, Pyrazinamide and Ethambutol. This case report presents the case of a 16-year-old girl who presented with a history of recurrent abdominal pain, vomiting and pyrexia. Radiological, laparoscopic, and histopathological findings were used for final diagnosis of this condition. The patient was treated using the anti-tuberculosis therapy for 6 months following which, she was able to make a full recovery.

A Rare Case of Sacral Pott’s Disease

Tuberculosis spondylitis, or “Pott’s Disease”, is a rare extrapulmonary manifestation of tuberculosis involving the spine. Very few cases of tuberculosis with sacral involvement have been reported, particularly in the United States, which may pose a diagnostic challenge for clinicians. We present a case report of extrapulmonary tuberculosis with sacral involvement in a 27-year-old male who initially presented with systemic symptoms thought to be related to a hematologic malignancy

Optic neuritis in a teenage girl with granulomatosis with polyangiitis

Introduction. Granulomatosis with polyangiitis (GPA), formerly known as Wegener?s granulomatosis, is characterized by necrotizing granulomatous inflammation in various tissues, including blood vessels, but primarily in the respiratory tract and kidneys. Clinical manifestations can be diverse, including inflammation of the eye and adnexa. Optic neuritis is a very rare ophthalmological manifestation of GPA, not previously described in a teenager. Case report. We presented a case of a 16-year-old girl with a rare extrapulmonary manifestation of GPA. The girl had a previous history of GPA and complained of a sudden blurred vision in the left eye. She was promptly referred to an ophthalmologist who noted a decreased visual acuity of 20/400 in the left eye. Colour vision was impaired in the spectrum of red colour. Clinical examination revealed normal anterior segment findings. On ophthalmoscopy, the left optic nerve oedema was noted. Urgent computed tomography of the left orbit showed a soft tissue mass around the optic nerve in the apex of the orbit. Magnetic resonance imaging confirmed the diagnosis of optic perineuritis. After pulse doses of methylprednisolone, the girl achieved complete resolution of vision in the left eye. Conclusion. If untreated, inflammation of the optic nerve can lead to a permanent loss of vision. Prompt diagnostic and adequate treatment of patients with GPA is needed in order to prevent vision-threatening complications and control the systemic disease.

Abdominal tuberculosis masquerading as carcinomatosis: Not difficult to miss!

Introduction: Abdominal tuberculosis (ATB) is a rare extrapulmonary manifestation of Mycobacterium tuberculosis infection. It usually presents with non-specific symptoms that can mimic other intra-abdominal conditions like acute appendicitis, Crohn’s disease, ovarian pathology, and intra-peritoneal carcinomatosis and is therefore, easy to overlook. Diagnosing ATB in the pediatrics population tends to be even more challenging as an obvious history of exposure may be difficult to obtain. Chronicity of symptoms and lack of Bacillus Calmette-Guerin (BCG) scar should raise suspicion. Diagnostic laparoscopic biopsy and histopathology provides definitive diagnosis. Case Report: This case report presents the case of a 16-year-old girl with a history of recurrent abdominal pain, vomiting, and pyrexia. At initial diagnostic laparoscopy, she underwent laparoscopic appendectomy. Vesicles were noted in the pelvis. The patient failed to improve. Exposure to tuberculosis (TB) was denied. Review of pre-operative computed tomography (CT), comprehensive re-laparoscopy, and histopathology of appendix were used for final diagnosis of this condition. The patient was treated using anti-TB therapy for six months following which, she was able to make a full recovery. Conclusion: Abdominal TB is very difficult to diagnose in young patients and should be considered in those presenting with vague, recurrent, or persistent abdominal symptoms. A high index of suspicion is needed for early diagnosis and prompt treatment of this condition. In patients with low or no identifiable risk factors for TB, definitive diagnosis is justified prior to the initiation of therapy.

S1728 COVID-19-Induced Colitis: A Novel Relationship During Troubling Times

INTRODUCTION: In December 2019, a novel coronavirus was identified known as acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the resulting disease called coronavirus disease 2019 (COVID-19). The majority of patients with COVID-19 primarily present to the hospital with respiratory symptoms, it is particularly important that physicians are familiar with rare extrapulmonary manifestations in the effort to reduce the delay of diagnosis, treatment and exposure to healthcare workers. CASE DESCRIPTION/METHODS: An 80-year-old Caucasian woman with a history of hypertension, hyperlipidemia and hypothyroidism presented to the ER with 5-days of fever, abdominal discomfort, nausea, diarrhea and hematochezia. The patient denied symptoms of chills, shortness of breath, cough, recent travel or ill-contacts, including exposure to COVID-19. Physical examination revealed a temperature of 100.6 F, a blood pressure of 130/65 mmHg, pulse of 83 bpm, respiratory rate of 15 bpm, and oxygen saturation of 96%. Lung auscultation was clear bilaterally. Abdominal examination revealed a soft abdomen, with positive bowel sounds and tenderness in the lower abdominal quadrants. Rectal exam was positive for bright red blood. A computed tomography (CT) scan of the abdomen revealed thickening of the descending colon with fat stranding- suggestive of an acute colitis (Figure 1). Outpatient colonoscopy completed 3 years prior, was normal. A white-blood count (WBC) of 6.4 K/uL. Liver function tests, lactic acid, lactic acid dehydrogenase (LDH) and coagulation profile were normal. C. difficile and influenza A and B testing were negative. COVID-19 RT-PCR testing returned positive. Rectal bleeding and diarrhea resolved and hemoglobin remained stable. Empiric antibiotic therapy and supportive measures were continued. In the setting of an active colitis, colonoscopy was deferred to the outpatient setting. The patient was discharged home with 10 days of metronidazole therapy and instructed to continue 14 days of home self-isolation. DISCUSSION: This case report highlights the significance of limiting fecal-oral transmission along with adding to the body of evidence that SARS-CoV-2 has the potential to directly infect the gastrointestinal tract in the absence of pulmonary involvement. With mounting evidence, we underline the importance of instituting appropriate precautions in patients who present with respiratory, digestive or other rare clinical presentations.Figure 1.: CT abdomen and pelvis showing thickening of the descending colon along with peri-colic fat-standing consistent with acute colitis.

Peritoneal tuberculosis: A case report on a rare cause of tumor marker elevation

Peritoneal tuberculosis (TB) is a rare extrapulmonary manifestation of TB with non-specific clinical characteristics which can produce test results mimicking malignancy and granulomatous peritonitis. This case describes a Filipino 59-year-old, nulliparous woman who was admitted with abdominal pain, ascites, and an elevated CA-125 level. Radiographically, peritoneal nodules were visualized and initial suspicion was high for malignancy. Following a bilateral salpingo-oophorectomy and peritoneal biopsy, histology was negative for malignancy but revealed non-caseating granulomas. She was discharged then readmitted with progressive abdominal pain, and a repeat laparoscopic biopsy yielded specimens with growth of acid-fast bacilli (AFB). A delay in diagnosis and treatment of tuberculous peritonitis increases mortality rates, making early diagnosis with laparoscopic biopsy of paramount importance in prompt diagnosis and initiation of therapy. This patient was initiated on standard anti-TB therapy and experienced no complications.