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S2123 Refractory Case of Malignant Eosinophilic Colitis Leading to Ischemic Colitis

Introduction: Eosinophilic colitis (EC) is a rare inflammatory condition involving eosinophilic infiltration of the mucosa in the absence of a secondary cause or peripheral eosinophilia. Clinically, EC presents with non-specific symptoms. We present a case of malignant EC that is refractory to different therapies. Case Description/Methods: A 30 years old male with known EC on azathioprine, pulmonary embolism and superior mesenteric venous (SMV) thrombosis onrivaroxaban, had multiple admissions with abdominal pain and hematochezia secondary to Clostridioides difficile (C. diff). His rivaroxaban and azathioprine were held given his hematochezia and recurrent infections. He presented a month later with worsening symptoms but C. diff was negative. CT abdomen/pelvis showed non-occlusive SMV and portal venous (PV) thrombosis with signs of ischemia of the sigmoid colon (Figure 1b). Patient underwent percutaneous transhepatic SMV/PV aspiration thrombectomy that was complicated by a large right hemothorax, causing hemorrhagic shock. Subsequent flexible sigmoidoscopy showed signs of colonic ischemia (Figure 1a). Colonic biopsies demonstrated active colitis without evidence of chronicity, and 60 eosinophils per high powered field. Patient underwent a subtotal colectomy with end ileostomy with clinical improvement immediately postoperatively. He was discharged on a steroid taper and apixaban. He was started on the interleukin-5 (IL-5) inhibitor benralizumab for his EC. Outpatient follow-up was notable for continued rectal bleeding. Flexible sigmoidoscopy showed diffuse severe erythema, contact bleeding, and friable mucosa throughout the rectal pouch (Figure 1c). Vedolizumab was started in combination with benralizumab, however, on long-term outpatient follow-up, no notable clinical or endoscopic improvements were noted on combination therapy. Multi-disciplinary decision in conjunction with patient resulted in planned proctocolectomy with permanent end ileostomy. Discussion: There are currently no FDA approved management options for EC. The IL-5 inhibitor Benralizumab is FDA approved for treatment of eosinophilic asthma and therefore it was worth a trial in this patient. In a small number of case reports, Vedolizumab has shown some clinical improvement as well as reduction in eosinophilia in EC patients. Due to the rarity of EC diagnosis, data for therapies in EC is severely lacking. To our knowledge, this is the first case of a patient with severe refractory EC that led to the development of ischemic colitis.Figure 1.: (a) shows an endoscopic image of ischemic colitis. (b), the red arrow points at the portal vein thrombosis and (c) shows diffuse severe erythema, contact bleeding, and friable mucosa throughout the rectal pouch.

S2029 Epiploic Appendagitis: A Red Herring?

Introduction: Epiploic appendagitis (EA) is a rare cause of acute abdominal pain that has a relatively benign course. The importance of identifying EA as a clinical mimicker is crucial to avoid unnecessary hospitalizations, antibiotic use, and surgery. Although no trigger has been established as a cause for EA, it is hypothesized that systemic inflammation can lead to an EA attack. Case Description/Methods: A 43-year-old White female with no significant GI history presented with 2 days of sudden onset, sharp, non-radiating, worsening left lower quadrant (LLQ) with nausea. Initial blood work was unremarkable. CT abdomen revealed a hyper-attenuating ring lesion along the anti-mesenteric margin adjacent to the distal descending colon, along with mesenteric lymph nodes consistent with epiploic appendagitis. She was managed conservatively with complete resolution of symptoms. A few years later, she presented again, with similar abdominal complaints. Repeat abdominal imaging showed recurrence of EA in the same location. Few shotty mesenteric lymph nodes were identified. She was treated conservatively for EA. A few more years passed, and she now had another episode of recurrent LLQ pain, CT abdomen showed findings consistent with EA along with a short segment of mural thickening and mild hyper-enhancement in the mid descending colon. Colonoscopy revealed a large circumferential mass in the sigmoid colon with an apple core lesion in the proximal sigmoid colon with luminal narrowing. Biopsy revealed an adenocarcinoma. No lymph node involvement was noted. As the TNM staging was pT3 N0 M0, she underwent a sigmoidectomy with left colon and rectal end-to-end anastomosis (Figure). Discussion: Epiploic appendages are fat-filled serosal outpouchings of the colonic surface. They are connected to the colon by a vascular stalk. Acute epiploic appendagitis is theorized to be caused by torsion, underlying inflammation, or venous occlusion of the appendage. CT scan is the gold standard for diagnosing EA and helps rule out other intra-abdominal pathologies. Recurrent and persistent EA is very rare and may mask an underlying occult abdominal pathology. There have not been any reported cases of CRC that are associated with and possibly trigger EA. In patients with recurrent EA, after common causes of acute abdominal pain are ruled out, evaluation for intestinal/intraluminal pathologies, especially colorectal malignancy should be considered as they are not readily apparent on CT scans.Figure 1.: A: Red arrow showing an inflamed epiploic appendage during initial presentations. B: Red arrow showing epiploic appendagitis. Green arrow with colonic wall thickening in the descending colon, with adjacent EA. 3: Colonoscopy showing the large friable mass in the sigmoid colon.

Monoclonal plasma cells with normal phenotype can lead to diagnosis of small B-cell lymphoma.

A 66-year-old man was referred for non-regenerative anaemia (Hb 114 g/L) and monoclonal IgG Kappa gammopathy (29.9 g/L). Biochemical test results showed normal serum creatinine and calcium and slight increase beta2-microglobulin (3.21 mg/L). Bone marrow examination revealed 3% plasma cells (Figure 1A May-Grünwald-Giemsa, ×100 objective, blue arrows) and 9% lymphocytes (Figure 1A red arrows) without morphological changes related to malignancy. Flow cytometric immunophenotyping showed CD38-positive, CD138-positive plasma cells with Kappa monotypic expression and without aberrant expression of CD45, CD19, CD117, CD56, CD81 and CD27 (Figure 1B). Next generation sequencing of sorted plasma cells revealed MYD88 L265P mutation (VAF 0.22). These results were not in favour of monoclonal gammopathy of undetermined significance (MGUS) and led us to look for B-cell lymphomas. Flow cytometric immunophenotyping of lymphocytes, showing Kappa monotypic B-cells population (Figure 1B) with coexpression of CD19, CD20, CD79a and without CD5, CD23, CD10, was finally indicative of lymphoplasmacytic lymphoma. Plasmacytic differentiation in B-cells lymphomas is a well-known phenomenon [1, 2] that can be challenging for differential diagnosis, especially with MGUS and multiple myeloma (MM). In MGUS and MM, plasma cells typically exhibit aberrant phenotype with loss of CD19 and CD45, expression of CD56 and/or CD117 and/or lack of CD81 and/or CD27 [3, 4]. Thus, the presence of a monoclonal population of plasma cells with a normal phenotype should prompt us to look for B-cells lymphomas [5]. AC, JC and JBR wrote the paper. JBR took the pictures. BR and PC performed the bone marrow examination. AC and JBR performed flow cytometric studies, and JC performed molecular studies. This study was supported by Centre Hospitalier Universitaire de Toulouse. The authors have no competing interests. This manuscript respects ethic policy of CHU Toulouse for treatment of human research participants. The authors did not obtain written informed consent from the patient but the patient did not object to his data being used for research purposes (as required by ethic policy of CHU Toulouse). Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Spontaneous Thoracic Spinal Epidural Hematoma During Pregnancy

Spontaneous Thoracic Spinal Epidural Hematoma During Pregnancy

A Young Man With Epigastric Abdominal Pain

A Young Man With Epigastric Abdominal Pain

P486 Disseminated Cryptococcosis diagnosed on fine needle aspiration cytology

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PMObjectives (Case)A 48-year-old male with no prior comorbidities presented to our infectious disease clinic with intermittent low-grade fever and gradual progressive swelling in his left axilla for 3 months. On further probing, the patient also gives a history of weight loss of around 7 kg. The patient belonged to a northern state of the Indian subcontinent and owned a grocery shop, where he worked. There was no recent or remote travel history, no history of exposure to animals or birds, no high-risk behavior, and no past or known contact history of tuberculosis. Still, in an endemic country like India and in this given clinical scenario, we kept tubercular lymphadenitis as the first differential and investigated the case further.Methods (Investigation)A contrast-enhanced computed tomography (CECT) of the chest and abdomen was done, showing multiple enlarged mediastinal and axillary lymph nodes with bilateral adrenal mass (Fig. 1). To further evaluate the etiology, a fine needle aspiration of the left axillary swelling was done. A hematoxylin and eosin (H and E) stain of the same showed the presence of numerous organisms of varying sizes present both intracellularly and extracellularly along with chronic inflammatory cells (Fig. 2a). Based on this picture, differentials of Histoplasma, Cryptococcus, or Toxoplasma were kept. But considering the empty spaces (halos) which probably represent the capsule and variability in the size, a strong possibility of Cryptococcus was kept. Serum cryptococcal antigen (latex agglutination) was negative but eventually, the fungal culture of the aspirated sample grew cream-colored, shiny dome-shaped, mucoid colonies on Sabouraud Dextrose Agar suggestive of Cryptococcus (Fig. 2b). The same was confirmed on Bird Seed Agar and Matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) mass spectrometry (MS). Gene Xpert of the aspirated sample was negative and serum cortisol with serum adrenocorticotropic hormone (ACTH) were under normal limits.Results (Diagnosis)A diagnosis of disseminated cryptococcosis was made based on the involvement of more than two non-contiguous sites (mediastinal with axillary lymph nodes and adrenal gland). The patient was initially started on liposomal Amphotericin B (5 mg/kg intravenous daily) with which he improved clinically. Same was continued for 2 weeks and later he was shifted to fluconazole 400 mg daily. As of now, the patient is on his 3rd month of fluconazole and doing well on follow-up.ConclusionCryptococcus (Cryptococcus neoformans and Cryptococcus gattii) is an encapsulated yeast causing invasive fungal infection, with vast majority occurring in immunocompromised host1. It has a global distribution, predominantly involving the central nervous system (CNS) and lung. Management of non-CNS and non-pulmonary cryptococcosis is tricky as looking for dissemination is key (as the initial choice of agent varies)2. Adrenal involvement in Cryptococcosis is uncommon (as seen in our case). Examination of FNAC samples for Cryptococcus is also challenging as other microbes can also closely mimic the same. Finally, in a tuberculosis endemic country like India, clinical symptoms of Cryptococcal lymphadenitis can closely resemble tubercular lymphadenitis, so empirical therapy may be risky.Figure 1 Axial CT Chest images showing multiple enlarged mediastinal lymph nodes (red arrow).Figure 2a Fine needle aspiration cytology (FNAC) from the left axillary swelling stained with hematoxylin and eosin showing numerous organisms of varying size present both intracellularly (black arrow) and extracellularly with surrounding halos in a background chronic inflammatory cells.Figure 2b Fine needle aspirate sample incubated at 37 0C on Sabouraud Dextrose Agar with gentamicin showing cream-colored, dome-shaped, shiny, mucoid colonies with smooth edge (characteristic of Cryptococcus).Sources:Iyer KR, Revie NM, Fu C, Robbins N, Cowen LE. Treatment strategies for cryptococcal infection: challenges, advances and future outlook. Nat Rev Microbiol. 2021 Jul;19(7):454–66.Clinical Practice Guidelines for the Management of Cryptococcal Disease: 2010 Update by the Infectious Diseases Society of America | Clinical Infectious Diseases | Oxford Academic [Internet]. [cited 2022 Jul 28]. Available from: https://academic.oup.com/cid/article/50/3/291/392360

Runx2 regulates chromatin accessibility to direct the osteoblast program at neonatal stages.

SUMMARYThe transcriptional regulator Runx2 (runt-related transcription factor 2) has essential but distinct roles in osteoblasts and chondrocytes in skeletal development. However, Runx2-mediated regulatory mechanisms underlying the distinctive programming of osteoblasts and chondrocytes are not well understood. Here, we perform an integrative analysis to investigate Runx2-DNA binding and chromatin accessibility ex vivo using neonatal osteoblasts and chondrocytes. We find that Runx2 engages with cell-type-distinct chromatin-accessible regions, potentially interacting with different combinations of transcriptional regulators, forming cell-type-specific hotspots, and potentiating chromatin accessibility. Genetic analysis and direct cellular reprogramming studies suggest that Runx2 is essential for establishment of chromatin accessibility in osteoblasts. Functional enhancer studies identify an Sp7 distal enhancer driven by Runx2-dependent binding and osteoblast-specific chromatin accessibility, contributing to normal osteoblast differentiation. Our findings provide a framework for understanding the regulatory landscape encompassing Runx2-mediated and cell-type-distinct enhancer networks that underlie the specification of osteoblasts.

Endovascular Treatment of a Giant Iliac Vein Aneurysm After a Traumatic Arteriovenous Fistula

A 60 year old man with a history of a military mine injury 30 years previously presented with chronic leg swelling and a non-healing ulcer. Computed tomography angiography (CTA) revealed a giant iliac venous aneurysm (Figure A; red arrow) due to a chronic arteriovenous fistula (green arrows) in the proximal superficial femoral artery (SFA; mine fragments indicated by the blue arrows). An iliac limb stent graft (16 – 23 mm × 100 mm; W.L. Gore & Associates, Flagstaff, AZ, USA) was placed via an open antegrade common femoral artery approach into the SFA.

No Symptoms for Over 70 Years! Incidentally Discovered Congenital Dysplasia of Infrarenal Aorta

A 75 year old female with a past history of pulmonary embolism was admitted with dyspnoea. Computed tomography angiography unexpectedly revealed a significantly narrowed and completely occluded abdominal aorta at the infrarenal level. She did not have any intestinal or lower limb problems, but she had had resistant hypertension for 40 years. Bilateral femoral, popliteal, and pedal pulses were palpable. The superior mesenteric artery (violet arrow), the arc of Riolan (white arrows), and the inferior mesenteric artery (red arrow) were dilated, providing adequate blood flow to the abdomen, pelvis, and lower limbs.

S-Shaped Fused Azacorannulene Dimer: Structural and Redox Properties

S-Shaped Fused Azacorannulene Dimer: Structural and Redox Properties

Fatal Case of EBV-negative Posttransplant Lymphoproliferative Disorder With Hemophagocytic Lymphohistiocytosis in an Adult Kidney Transplant Recipient.

Fatal Case of EBV-negative Posttransplant Lymphoproliferative Disorder With Hemophagocytic Lymphohistiocytosis in an Adult Kidney Transplant Recipient.

A Rare Case of an Abdominal Giant Mass Induced by Pancreatitis

Question: A 54-year-old man experienced intermittent abdominal pain for more than 4 months, with the physical examination finding of epigastric tenderness. He had a long history of alcohol consumption. Laboratory tests showed significantly elevated amylase (404 U/L) and lipase (1071 U/L), and the clinician highly suspected pancreatitis. To clarify the diagnosis and the severity of the patient’s condition, the patient underwent abdominal computed tomography (CT) and magnetic resonance imaging, which showed increased fat density around the pancreas, visible as multiple patchy exudative shadows (Figure A, red arrows) with blurred borders and dilated pancreatic ducts.

Intraoperative Management of a Severely Kinked Endotracheal Tube and Difficult Airway.

This figure is a lateral cervical radiograph of a nasally intubated 16-yr-old patient with Crouzon syndrome obtained after completion of cranial fossa surgery for Chiari malformation and returning to supine from a prone position. The standard endotracheal tube was severely kinked in the nasopharynx, as shown in the image, and the location of the kinking is indicated with a red arrow. This was likely caused by the warming of the endotracheal tube and the patient’s unique pharyngeal anatomy. The tracheal intubation of the patient was difficult, requiring 11 attempts due to midface hypoplasia, obesity, macroglossia, and cervical spine instability. After the start of surgery, elevated airway pressures and the inability to pass a suction catheter suggested kinking of the endotracheal tube. Due to extremely difficult intubation, endotracheal tube replacement was not attempted. Because the severely kinked endotracheal tube limited inspiratory and expiratory airflow, adequate tidal volume was achieved by increasing peak inspiratory pressure.1 Intermittent measurement of plateau pressure with an expiratory hold yielded additional information about the pressure at the alveoli. Because expiration was passive, increasing the expiratory time facilitated exhalation and reduced the risk of breath stacking.2 A helium–oxygen mixture can also be used to improve ventilation by reducing gas density, increasing the likelihood of maintaining laminar flow across the point of obstruction, and improving bulk flow.3 If the patient can tolerate permissive hypercapnia, a reduction in minute ventilation is also an option to minimize turbulent flow. The use of a wire-reinforced tube is often recommended to prevent endotracheal tube kinking in such a patient.The authors declare no competing interests.

Atypical Type II Endoleak After EVAR: the Left Behind Artery

An 87 year old man with previous endovascular infrarenal abdominal aneurysm repair (Endurant IIS, Medtronic, Santa Rosa, CA, USA) presented four years later with a type II endoleak and aneurysm sac enlargement. Computed tomography angiography suggested and the angiography confirmed the origin of the endoleak. (A) A left lumbar artery (blue arrow) supplied by (A, B) a deep circumflex iliac artery collateral (red arrows). After catheterisation and microcatheter navigation (Marathon, Medtronic, Minneapolis, MN, USA), embolisation of the aneurysm sac was performed successfully using coils and ethylene vinyl alcohol.Image 1

An Unusual Cause of Obstructive Jaundice

Question: A 45-year-old man presented with painless obstructive jaundice for 1 month. His past medical history was unremarkable. Significant laboratory results included total bilirubin of 73.4 μmol/L (normal 5.1-20 μmol/L), direct bilirubin of 46.5 μmol/L (normal <6.1 μmol/L), alanine transaminase of 168.3 U/L (normal 9-50 U/L), alkaline phosphatase of 438 U/L (normal 50-135 U/L) and gamma-glutamyl transferase of 1321.6 U/L (normal 10-60 U/L). Abdominal ultrasonography showed a gallstone in the common hepatic duct with intrahepatic ductal dilation, and the gallbladder was atrophic. Contrast-enhanced computed tomographic (CT) scan in a dual-energy mode showed luminal distension of gallbladder neck (Figure A, white arrow), with hepatic hilar stenosis (Figure A, blue arrow) and bilateral intrahepatic ductal dilation. Coronal virtual monoenergetic image reconstruction at 40 keV clearly showed an intraluminal lesion with hypodensity in gallbladder neck (Figure B, red arrow). The spectral Hounsfield unit curve showed the decreased attenuation values of the lesion as the energy level decreased (Figure C). What is the most likely diagnosis? Look on page 197 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Dual-energy CT suggested that the lesion was a cholesterol gallstone. Magnetic resonance cholangiopancreatography (MRCP) was then performed and confirmed a stone (Figure D, white arrow) in the gallbladder neck, with external compression of the common hepatic duct and dilation of the intrahepatic biliary duct, highly suggestive of Mirizzi syndrome (MS). In addition, a long cystic duct running parallel to the common bile duct with low insertion was found. Subsequent cholecystectomy confirmed a 1.7-cm cholesterol gallstone in the neck of the gallbladder causing hepatic hilar stricture, which was consistent with MS. The patient had an unremarkable recovery. MS, as a rare complication of gallstone disease, refers to impaction of a gallstone in the gallbladder neck or cystic duct causing obstruction of the extrahepatic bile duct.1Abou-Saif A. Al-Kawas F. Complications of gallstone disease: Mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus.Am J Gastroenterol. 2002; 97: 249-254Crossref PubMed Google Scholar MS can be tricky and may mimic cholangiocarcinoma, especially when gallstones are radiolucent on conventional CT.2Chen Y. Chang C. Liu K. Mirizzi syndrome due to a large radiolucent gallstone.Am J Gastroenterol. 2016; 111: 599Crossref PubMed Scopus (2) Google Scholar With the ability to differentiate materials on the basis of their differential attenuation at 2 different energy levels, dual-energy CT can help to identify the composition of internal body constituents, such as gallstones. Previous studies have reported that dual-energy CT can increase the conspicuity of isoattenuating gallstones.3Soesbe T.C. Lewis M.A. Xi Y. et al.A technique to identify isoattenuating gallstones with dual-layer spectral CT: an ex vivo phantom study.Radiology. 2019; 292: 400-406Crossref PubMed Scopus (15) Google Scholar In this case, dual-energy CT was first used to diagnose MS, clearly showing the gallstone in the gallbladder neck as the cause of the hepatic hilar obstruction, and to provide a diagnostic clue to confirm MS. This technique can potentially reduce the need for further imaging, such as MRCP, leading to a reduction in imaging cost and time to diagnosis for selected patients.

Lateral Decubitus Position Enables Further Advancement of the Bronchoscope into the Lung Periphery.

Lateral Decubitus Position Enables Further Advancement of the Bronchoscope into the Lung Periphery.

Structure of a subnanometer-sized semiconductor Cd14Se13 cluster

Structure of a subnanometer-sized semiconductor Cd14Se13 cluster

An Unexpected Esophageal Lesion in a Patient With Muir-Torre Syndrome

Question: In a 52-year-old female patient with a history of sebaceous gland neoplasms of the skin (carcinoma resected in 2017 and several subsequent adenomas) and positive family history for early-onset colorectal cancer (father at the age of 39 years), Muir-Torre syndrome was suspected. This is a rare variant of Lynch syndrome (LS; approximately 10% of individuals with LS) clinically defined by the typical LS tumor spectrum (colorectal cancer as well as extracolonic tumors, eg, endomtetrial/ovarian cancer, urinary tract cancer) and additional increased risk for characteristic skin neoplasms (especially sebaceous gland neoplasms and keratoacanthoma). DNA mismatch-repair (MMR) deficiency resulting in an accumulation of somatic mutations throughout the genome, also affecting genes involved in carcinogenesis, causes LS. Genetic testing identified a pathogenic germline mutation in MSH2 (mutS homolog 2) on chromosome 2p21 and confirmed the diagnosis in 2018. Compliant with current international guidelines, the patient was included in a specific tumor-screening program. In dermatologic follow-up examinations, basal cell carcinoma and squamous cell carcinoma of the skin were detected. By annual surveillance colonoscopies up to the present, 4 colorectal adenomas with sizes from 2 to 15 mm were resected. On an individual basis, and not covered by guidelines, we performed yearly surveillance esophagogastroduodenoscopy (EGD). Interestingly, at the age of 57 years, a small irregular and slightly elevated lesion (8 mm) with small central erosion (Figure A, arrow) was observed (Paris 0-IIa) in the mid-esophagus (25 cm from incisors). The central part of the lesion stained negative during chromoendoscopy with Lugol’s iodine (1%) (Figure B, arrow) and showed an irregular surface pattern with virtual chromoendoscopy (NBI mode; narrow band imaging) (Figure C). Therefore, malignancy was suspected, and the lesion was removed en bloc by means of rubber-band ligation assisted endoscopic mucosal resection (Figures D and E). Of note, the patient was never a smoker and only occasionally consumed alcohol. Endoscopies were performed with Olympus GIF-H190 endoscopes (Olympus, Hamburg, Germany). Which diagnosis do you suspect and is this lesion LS associated? Look on page 189 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Histopathologic and immunohistochemical examination of the resected tumor revealed poorly differentiated invasive squamous cell carcinoma (pT1a, Pn0, V0, R0, G3) (Figure F, hematoxylin and eosin [HE] stain, ×40) with focal invasion of the lamina muscularis mucosae (Figure G, HE, ×200, arrow). Molecular microsatellite instability testing discovered instability in 4/5 markers (BAT-26, NR-21, BAT-25, and NR-24; NR-27 was stable). When an LS-associated tumor was suspected, MMR protein immunohistochemistry showed a loss of MSH2 expression within the neoplastic cells (Figure H, ×200, red arrow) while surrounding tissue stained positive for MSH2 (Figure H, black arrow) and MLH1 expression was unaffected in neoplastic (Figure I, ×200, red arrow) and nonneoplastic (Figure I, black arrow) cells. Computed tomography and endoscopic ultrasound did not find any distant or lymph-node metastases, and there was no residual tumor in a follow-up endoscopy. Because of poor tumor differentiation and invasion of the lamina muscularis mucosae (m3), additive radiotherapy (50.4 Gy/59.92 Gy boost in 28 fractions) was recommended after discussion by the tumor board. This is the first description of an LS/Muir-Torre syndrome–associated squamous cell carcinoma of the esophagus in a patient without typical risk factors for this tumor entity. Moreover, we show in-depth molecular characterization to prove LS association. Only rarely have adenocarcinomas of the esophagus been reported1Sweetser S. Chandan V.S. Baron T.H. Dysphagia in Lynch syndrome.Gastroenterology. 2013; 145: 1167-1168Abstract Full Text Full Text PDF Scopus (6) Google Scholar in LS. Until recently, squamous cell carcinoma of the skin was not counted as typical skin manifestation of Muir-Torre syndrome, but an association has been demonstrated.2Ykema B.L.M. Adan F. Crijns M.B. et al.Cutaneous squamous cell carcinoma is associated with Lynch syndrome: widening the spectrum of Lynch syndrome-associated tumours.Br J Dermatol. 2021; 185: 462-463Crossref PubMed Scopus (7) Google Scholar Of note, our patient also suffered from squamous cell carcinoma of the skin. In conclusion, clinicians should carefully consider esophageal neoplasms as a rare manifestation of LS. Despite limited data supporting EGD surveillance in LS and in contrast to current guidelines, upper endoscopy could be easily performed along with routine colonoscopy in an effort to prevent morbidity and mortality from upper GI manifestations of LS (early-stage cancer observed in about 1.5% of asymptomatic patients3Farha N. Hrabe J. Sleiman J. Beard J. et al.Clinically actionable findings on surveillance EGD in asymptomatic patients with Lynch syndrome.Gastrointest Endosc. 2022; 95: 105-114Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar).

Very large infrarenal infected aortic pseudoaneurysm in a healthy young patient.

Although rare, infected aortic aneurysms are associated with high morbidity and mortality, despite appropriate treatment.1 An afebrile 33-year-old healthy man had visited the emergency department with a 3-day history of sharp abdominal pain. Initial computed tomography revealed an infrarenal pseudoaneurysm (150 mm; A), deep vein thrombosis from the inferior vena cava to both iliac veins (B and C; red arrows), and left hydronephrosis secondary to extrinsic compression of the ureter (B; blue arrow).

Tuning Ice Nucleation by Mussel-Adhesive Inspired Polyelectrolytes: The Role of Hydrogen Bonding

Tuning Ice Nucleation by Mussel-Adhesive Inspired Polyelectrolytes: The Role of Hydrogen Bonding