Sick Contacts Research Articles

A Shallow Large Ulcer on the Ileocecal Valve in a Young Man With Ulcerative Proctitis

Question: A 25-year-old man was presented to the emergency department with fever, abdominal pain, diarrhea, fatigue, and malaise for a week. He denied any history of cough, weight loss, chills, night sweats, upper respiratory tract symptoms, nausea, or vomiting. There was no history of smoking, chronic use of medications such as nonsteroidal antiinflammatory drugs (NSAIDs), recent sick contact, recent travel, or known ingestion of contaminated foods.

Unusual Diagnosis of Multiple Small Bowel Masses

Question: A 76-year-old man with hypertension and well-controlled diabetes presented to the hospital with poor appetite, abdominal distention, and intermittent nausea and vomiting for several weeks. He reported no fevers, sick contacts, or recent travel, but had an 18-pound unintentional weight loss during this time period with inability to tolerate solids for 4 weeks. Physical examination was notable for abdominal distension and tympany to percussion. Blood work showed a white blood cell count of 4,200/μL with a normal differential, hemoglobin of 13.1 g/dL, hematocrit of 38.2%, red blood cell count of 4.5 million/μL, and a platelet count of 239,000/μL. The metabolic profile was only notable for a potassium level of 2.8 mmol/L. There was no elevation in creatinine, calcium, or alkaline phosphatase. A computed tomography (CT) abdomen/pelvis scan without contrast showed multiple small bowel masses resulting in a small bowel obstruction, with the most proximal small bowel mass located in the third portion of the duodenum (Figure A). After NG tube decompression, enteroscopy was performed and identified an ulcerated mass near the ampulla measuring approximately 4 cm, and a single 1.5-cm ulcerated mass with adjacent edematous and friable mucosa in the third portion of the duodenum (Figure B). Duodenal biopsy showed small intestinal mucosa with prominent lymphoplasmacytic infiltrates in the lamina propria. Notably, these cells stained positive for CD138 on immunohistochemistry (Figure C). Serum protein electrophoresis and urine protein electrophoresis did not reveal any significant monoclonal spike or paraproteins. A subsequent bone marrow biopsy from the iliac crest was notable for an increased number of abnormal plasma cells, with less condensed nucleus and nucleolus. These abnormal plasma cells constituted 7% of the marrow (reference range, 0%–5%). The rest of the marrow differential consisted of the following: 63% myeloid cells (reference range, 30%–67%), 5% lymphocytes (reference range, 3%–17%), 25% erythroid cells (reference range, 10%–35%), and zero blasts (reference range, 0.3%–5%). There was no expression of kappa or lambda light chain. A subsequent whole-body positron emission tomography (PET)/CT showed no lytic lesions.

Unusual Combination of Gastrointestinal Pathogens Detected by Multiplex PCR

Abstract Introduction/Objective Infectious gastroenteritis (IGE) is a common but complex entity which is a major cause of global morbidity and mortality. IGE is caused by a wide range of etiologic agents such as viruses, bacteria, and parasites. In the United States there are approximately 373 million of IGE cases per year. Most cases of IGE resolve without identification of a specific pathogen. Multiplex molecular assays allow identification of multiple possible pathogens with rapid turnaround time and increased sensitivity, facilitating to formulate an effective treatment plan and control measures. Methods/Case Report We present a case of a pediatric patient with no significant past medical history who has been having runny stools that have progressively worsened in the last 3 months and 2 days history of bloody stools with mucus before emergency room presentation. She had no fever, vomiting, joint pain, oral ulcer, and rash. Physical exam showed that the patient appeared well, nontoxic, and vital signs were within normal limit. Copious rhinorrhea was noted. She was at 50th percentile for age on the growth chart. Family denied any recent travel or sick contacts however stated that all the family members have been on well water. Complete blood count was obtained and showed a platelet count of 669 x 10(3)/mcL and WBC of 16.6 x 10(3)/mcL with differential showing absolute lymphocytosis, absolute monocytosis and absolute eosinophilia. Biofire FilmArray gastrointestinal panel performed on the stool detected Giardia lamblia, Campylobacter, Shiga-like toxin producing E. coli and Adenovirus F 40/41. Repeat of the panel per protocol detected the same four pathogens. Results (if a Case Study enter NA) N/A. Conclusion This case report highlights the significance of detecting multiple causative pathogens. While long term watery diarrhea may guide clinicians to malabsorptive process and the use of well water to Giardia, a sensitive and specific multiplex assay can detect all the pathogens involved in the disease process and greatly simplify the treatment plan for patients. This unusual combination of pathogens can explain the unique symptomology of the patient including long term watery diarrhea, recent bloody diarrhea as well as copious rhinorrhea and failure to thrive.

HYPEREOSINOPHILIA LEADS TO PRIMARY IMMUNODEFICIENCY DIAGNOSIS

<h3>Introduction</h3> In the absence of prior infections, idiopathic hypereosinophilia should prompt consideration of a primary immunodeficiency (PID). <h3>Case Description</h3> We present an 8-month-old previously healthy male admitted for persistent hypoxia and suspected bronchiolitis. This patient did not present with fever, weight loss, adenopathy, chronic rash, GI symptoms, or medication use. There was no travel history, sick contacts, or pertinent family history. Laboratory results were significant for negative viral panel and absolute eosinophil count > 34,000. Chest CT showed scattered ground glass opacities without cavitation or bronchiectasis. Bone marrow biopsy was negative for malignancy. T cell (beta) and B cell gene rearrangement studies were negative, as well as FIP1L1-PDFGFRA, FISH studies, and myelodysplastic panels. Cardiac workup, infectious/parasitic tests, tryptase, and B12 levels were normal. The patient was started on systemic steroids with dramatically improved hypereosinophilia. Workup revealed low IgG/IgA levels, with normal IgM. Vaccine titers to tetanus, diphtheria and Hib were absent, despite up-to-date immunizations. Genetic testing revealed a pathogenic mutation in the CD40L gene, indicating X-linked hyper IgM syndrome (HIGM). Pneumocystic jirovecii was confirmed with bronchoscopy. TMP-SMX treatment allowed for weaning off steroids. The patient was started on IVIG and is awaiting bone marrow transplant. <h3>Discussion</h3> HIGM often presents in infancy with increased susceptibility to sinopulmonary infections. Unlike other PIDs with clinical manifestations of atopy, HIGM does not often present with eosinophilia. Opportunistic infections, including PJP, may drive eosinophil production through antigenic stimulation of TH2 cells. This case illustrates the importance of immunologic considerations in patients with unexplained hypereosinophilia, even without a significant infectious history.

PMON40 A Rare Etiology of Chronic Diarrhea: Zollinger-Ellison Syndrome

Abstract Introduction Zollinger-Ellison Syndrome (ZES) is a rare etiology of chronic diarrhea caused by a gastrin-secreting neuroendocrine tumor. Early suspicion can prevent multiple readmissions for recurrent diarrhea thus improving clinical outcomes through prompt diagnosis and treatment, as the following case highlights. Case presentation A 74-year-old African-American female with hypertension and chronic atrial fibrillation presented to the ED complaining of watery, non-bloody diarrhea for the past 3 weeks. She reports her symptoms worsened after completing a course of amoxicillin for pharyngitis one week prior. On further questioning, she reported intermittent diarrhea for over 20 years lasting approximately two days per episode. She denied recent travel, sick contacts, pet reptiles, and recent ingestion of undercooked meat. On arrival, she was afebrile and hemodynamically stable. She was admitted for an acute kidney injury with an elevated creatinine of 3.23 mg/dL (N: 0.6-1.1 mg/dL) due to dehydration. Her renal function improved with fluids, but she developed bloody diarrhea for which gastroenterology was consulted. Stool studies were negative for Shiga-toxin, C. difficile, lactoferrin, and parasites. Computed Tomography of the abdomen showed enteritis with fluid noted throughout the colon consistent with colitis. Unprepped colonoscopy revealed blood throughout the length of the colon, suggestive of an upper gastrointestinal bleed. Esophagogastroduodenoscopy (EGD) revealed multiple bleeding duodenal ulcers controlled with hemostasis. Her symptoms improved and she was discharged home on oral pantoprazole, and told to follow up outpatient. Two weeks later, she denied any new episodes of diarrhea, and a random serum gastrin level was elevated at 413 pg/mL (N: &amp;lt;180 pg/mL). Repeat gastrin level off pantoprazole for 7 days was also elevated at 678 pg/mL, and a serum Chromogranin A level was elevated at 629 pg/mL (N: &amp;lt;390 pg/mL). Repeat EGD found her Gastric pH to be 1 with multiple non-bleeding duodenal ulcers. Somatostatin receptor scintigraphy revealed a high intensity signal consistent with a duodenal gastrinoma causing ZES. She elected for surgical resection, and was discharged home on high dose pantoprazole. Three months later, she stated that her diarrhea had completely resolved. Conclusion This case confirms ZES as a rare cause of chronic diarrhea in the setting of multiple duodenal ulcers refractory to proton pump inhibitors. Diagnosis can be made with a fasting serum gastrin level &amp;gt;1000 pg/mL or &amp;gt;400 pg/mL with a gastric pH &amp;lt;1. A Secretin Stimulation Testing can also be used. Treatment starts with high dose proton pump inhibitors, octreotide for hormonal regulation, and surgical resection if necessary. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

DYSPNEIC AFTER EVERY COVID-19 SHOT: SUSPECTED BNT162B2 MRNA VACCINE-RELATED, DRUG-INDUCED PULMONARY EOSINOPHILIA

DYSPNEIC AFTER EVERY COVID-19 SHOT: SUSPECTED BNT162B2 MRNA VACCINE-RELATED, DRUG-INDUCED PULMONARY EOSINOPHILIA

WHEN TREATING ACNE GOES WRONG: A CASE OF BACTRIM-INDUCED ARDS IN A HEALTHY YOUNG WOMAN

WHEN TREATING ACNE GOES WRONG: A CASE OF BACTRIM-INDUCED ARDS IN A HEALTHY YOUNG WOMAN

TULAREMIA PRESENTING AS LARGE GI ULCERATION AND HEMORRHAGE

TULAREMIA PRESENTING AS LARGE GI ULCERATION AND HEMORRHAGE

ACUTE PERICARDITIS CAUSED BY COVID-19 INFECTION AND ITS MANAGEMENT

ACUTE PERICARDITIS CAUSED BY COVID-19 INFECTION AND ITS MANAGEMENT

DISSEMINATED BLASTOMYCOSIS PRESENTED WITH ADRENAL MASS

DISSEMINATED BLASTOMYCOSIS PRESENTED WITH ADRENAL MASS

S2939 Ashwagandha Toxicity: A Rare Case of Drug Induced Liver Injury (DILI)

Introduction: The pursuance of natural and herbal remedies by many has brought with it further knowledge of the many causes of Drug Induced Liver Injury (DILI). Many of these "natural" over-the-counter (OTC) supplements may not be benign due to the lack of scientific analysis and unregulated production. Ashwagandha is a supplement used for memory enhancement, management of anxiety, and general increase in vitality. We present a case of Ashwagandha DILI in a healthy 36-year-old man. Case Description/Methods: A 36-year-old male presented to our institution with 1 week of fatigue, jaundice, nausea and subjective fevers. Upon presentation he was hemodynamically stable and afebrile. Physical exam was notable for jaundice without other stigmata of liver disease or mental status changes. He was found to have acute liver injury with lab chemistries remarkable for AST= 1482 U/L, ALT= 1375 U/L, Tbili= 22.3 mg/dL, alkaline phosphatase= 202 U/L and an INR of 1.6. He denied alcohol and drug use, recent travel or sick contacts. Medications list was notable for cetirizine, diphenhydramine (both taken as needed), OTC testosterone supplements, OTC apple cider vinegar gummies BID and OTC ashwagandha gummies BID. Workup was negative for autoimmune, infectious, metabolic, obstructive and vascular causes of liver injury. Acetaminophen level and urine drug screen were negative. Trans-jugular liver biopsy revealed evidence of acute portal and lobular hepatitis and cholestasis, suggestive of DILI. Patient's liver enzymes continued to downtrend (AST=929, ALT=765, Tbili=22.5) after withdrawal of his supplements and was discharged (Figure). Discussion: Ashwagandha causing DILI has been infrequently reported in the literature. One case series of 5 patients in Iceland and a single case in Japan reported that ashwagandha is an uncommon culprit linked to acute liver injury. None of the reported cases necessitated liver transplant. Average time to resolution and normalization of LFTs was 3.5 months and R values usually ranged in the mixed range (R value 2-5). The case series also revealed that ashwagandha's toxicity could be dose dependent, as higher peaks in LFT's were tied to recent increases in ashwagandha dosing. Although ashwagandha has been a rarely reported cause of DILI, a thorough history of medication and OTC supplements in patients with undifferentiated acute liver injury may yield more cases. Further study and reporting of DILI in the ever-growing supplement market appears to be required to minimize potential injury.Figure 1.: Tranjugular Liver Biopsy Findings.

S3224 Pylephlebitis Presumed to Be Secondary to a Perforated Diverticulum

Introduction: Pylephlebitis is acute thrombosis of the portal system in the setting of intraabdominal infection. Diagnosis is challenging since symptoms may be nonspecific, but early identification and management with broad spectrum antibiotics is essential. We present a case of pylephlebitis presumed to be secondary to a perforated diverticulum. Case Description/Methods: A 63-year-old African American male with colonic diverticulosis presented with recurrent fevers and chills of two weeks duration. He immigrated from Benin 8 years ago but denied recent travel or sick contacts. On presentation, patient was febrile to 103.1F with tachycardia (107 beats/minute). Physical examination was normal. Labs revealed leukocytosis (15.9 K/uL) and mildly elevated liver enzymes with hyperbilirubinemia (1.4 mg/dL). Abdominal imaging revealed two hepatic abscesses with a multifocal occlusive thrombus in the right hepatic vein and a nonocclusive thrombus in the right portal vein. He underwent image guided aspiration of the abscesses and was started on intravenous (IV) antibiotics and heparin infusion. Fluid cultures grew Fusobacterium nucleatum and blood cultures had no growth. Due to concerns for colonic bacterial translocation, colonoscopy was performed which showed diffuse diverticulosis throughout the colon without evidence of diverticulitis. Upon clinical improvement, patient was discharged on a 4-week course of ceftriaxone/metronidazole with a 12-week course of apixaban. Repeat abdominal ultrasound a month after discharge showed interval improvement of hepatic abscesses and resolution of portal vein thrombus. (Figure) Discussion: Pylephlebitis is a rare condition but frequently associated with intra-abdominal infections, mainly diverticulitis which is the likely source in this patient. Inflammatory bowel disease and recent abdominal surgery have also been described as sources. Diagnosis is established via imaging confirming portal vein thrombosis in setting of an intraabdominal infection. Gram-negative organisms are most commonly isolated. The mainstay of therapy is broad spectrum antibiotics for 4-6 weeks. The role of anticoagulation (AC) is controversial as robust evidence is lacking. However, it has been proposed that AC prevents bowel ischemia and infarction secondary to thrombus extension. Despite the risk of sepsis and bowel infarction, morbidity and mortality rates have improved in recent years as imaging modalities have advanced and antibiotic options have diversified. AC should be considered on case-by-case basis.Figure 1.: A) 2.8 cm rim-enhancing abscess with rim-sign/double target sign (blue arrow) seen in axial view of segment 8; B) Associated T2 hyperintense, T1 hypointense linear filling defect consistent with thrombus along course of right hepatic vein branches (orange arrow) adjacent to abscess; C) Associated perfusional changes/wedge-shaped edema and T2 hyperintensity in liver parenchyma (green arrow).

S3026 Hepatic Sarcoidosis Hiding Beneath Mesenteric Panniculitis

Introduction: Mesenteric panniculitis is a rare inflammatory disease that affects the adipose tissue of intestinal mesentery. The incidence of mesenteric panniculitis ranges from 0.16%-3.4%. Though its etiology is unknown, it has been linked to a range of conditions including vasculitides, malignancies, abdominal trauma, and autoimmune diseases. We present a case of a 32-year-old male with a history of chronic abdominal pain and unintentional weight loss who presented with worsening transaminitis eventually found to have mesenteric panniculitis and hepatic sarcoidosis. Case Description/Methods: A 32-year-old male with a history of sarcoidosis and pulmonary embolism, not compliant with medication, presented to the emergency department with a six-month history of sharp, intermittent, and diffuse abdominal pain. He denied any fevers, nausea, vomiting, diarrhea, changes in medications or diet, recent travel, or sick contacts. He also endorsed a 20-pound weight loss. On presentation, he was tachycardic to 121 and febrile to 100F. Labs were significant for a hemoglobin of 8.2, AST 105 U/L, ALT: 81U/L, and ALP 51 U/L. On physical exam, the abdomen was diffusely tender to palpation in the epigastric region and right upper quadrant. He was started on IV Ceftriaxone. Computed Tomography (CT) of the abdomen and pelvis revealed a hazy appearance of mesentery with numerous mesenteric lymph nodes suspicious of mesenteric panniculitis, hepatomegaly, multistational upper abdominal lymphadenopathy, and a 2.0 cm ill-defined hepatic lesion (Figure 1). Percutaneous liver biopsy revealed hepatic sarcoidosis and mesenteric panniculitis. He was initiated on a two-week tapered course of prednisone. Azathioprine was later added with marked improvement in his symptoms. Discussion: Mesenteric panniculitis is a rare fibroinflammatory condition of unknown etiology. There is limited understanding of the pathogenic mechanism, but it has been linked to autoimmune processes. Presenting symptoms are vague and highly variable, but abdominal pain is reported to be the most common. CT scan is the imaging modality preferred, however, diagnosis is established by histological confirmation. No specific treatment exists, but steroids have demonstrated promising results. Our case illustrates the need for maintaining a high index of suspicion for mesenteric panniculitis when evaluating patients with a history of autoimmune disease presenting with vague abdominal pain in addition to transaminitis.Figure 1.: CT scan (axial view) showing focal lesion in the liver and mesenteric lymphadenopathy.

ATYPICAL PRESENTATION OF MYCOBACTERIUM CHIMAERA PNEUMONIA FOLLOWING TRANSESOPHAGEAL ECHOCARDIOGRAPHY

ATYPICAL PRESENTATION OF MYCOBACTERIUM CHIMAERA PNEUMONIA FOLLOWING TRANSESOPHAGEAL ECHOCARDIOGRAPHY

S2509 Mantle Cell Lymphoma Presenting as Multiple Lymphomatous Polyposis: A Case Report

Introduction: Mantle Cell Lymphoma (MCL) typically presents with extensive lymphadenopathy, fevers, night sweats and unintentional weight loss. However, Multiple Lymphomatous Polyposis (MLP), MCL arising from the gastrointestinal tract, is an aggressive malignancy and is infrequently described. Case Description/Methods: A 68-year-old White man with atrial fibrillation and hypertension presented to the hospital with watery diarrhea, fatigue and intermittent epigastric pain for the past several weeks. He denied melena, hematochezia, heartburn, dysphagia, odynophagia, weight loss, loss of appetite, NSAID use, recent travel or sick contacts. There was no family history of gastrointestinal malignancy. No history of prior endoscopic evaluation. Physical exam was notable for brown stool on rectal exam. Further evaluation revealed Hgb 6.4, MCV 60.9, iron 43, TIBC 442 and iron saturation 10% consistent with iron deficiency anemia. Upper endoscopy was normal. Colonoscopy showed 8 6-16 mm polyps scattered throughout the colon, all of which were resected completely. Analysis showed a range of histology – 3 tubular adenomas, 1 serrated and 2 hyperplastic polyps. However, histology of 4 polypoid appearing lesions (Figure 1A) showed prominent nodular atypical submucosal lymphoid aggregates (Figure 1B) that were positive for CD20, cyclin D1, weak CD5, and negative for CD10 and CD23. This was consistent with the diagnosis of MCL. CT imaging showed diffuse lymphadenopathy, including bulky disease with a 16.6 x 10.6 cm small bowel mesenteric mass (Figure 1C), along with proximal small bowel and terminal ileal thickening. He was induced with 6 cycles of bendamustine-rituximab combination therapy and maintained on rituximab. A re-staging scan at 27 months showed no evidence of disease progression. Discussion: We present a case of MCL presenting as MLP with symptoms of anemia, diarrhea and epigastric pain. MCL is a rare B-cell non-Hodgkin's lymphoma that portends a poor prognosis, making early identification and diagnosis critical. Obstruction, GI bleeding, and perforation are common complications for MCL presenting as MLP. It is important to keep MLP on the differential when multiple small nodular or polypoid lesions are identified on colonoscopy. All different types of polyps should be resected or sampled during colonoscopy, and each evaluated by the pathologist to avoid missing clinically significant conditions. Early diagnosis is key to prevent morbidity and mortality in MLP as described in our case.Figure 1.: (A) polypoid lesion (B) nodular atypical submucosal lymphoid aggregates (C) 16.6 x 10.6 cm small bowel mesenteric mass.

S1978 A Rare Case of Leflunomide-Induced Colitis: Clinical, Endoscopic and Microscopic Findings

Introduction: Leflunomide-induced colitis is a rare entity, which can be difficult to diagnose. We present a case of an elderly woman with rheumatoid arthritis (RA) who complained of subacute diarrhea. Colonoscopy with biopsy was performed and investigation of inflammatory and infectious causes were negative. Cessation of leflunomide resolved diarrhea. A wide range of endoscopic findings and late-onset of symptoms makes this a challenging diagnosis. Our hope is to aid in the recognition of this drug-induced colitis to reduce hospitalization stays and improve treatment. Case Description/Methods: A 79-year-old female with a past medical history of RA, COPD and gout, presented to the hospital with 7 days of watery diarrhea. She reported more than 6 bowel movements daily. She denied recent sick contacts, travel, or changes in diet. Patient did not have a family history of inflammatory bowel disease or colorectal cancer. Vitals were stable. CT abdomen/pelvis demonstrated continuous wall thickening of the splenic flexure to rectum. Labs included CRP at 40.7, ESR at 58, and a positive fecal lactoferrin. Patient was empirically treated for infectious colitis with ceftriaxone and metronidazole. Stool cultures and C. difficile toxin were negative. Colonoscopy showed areas of congested and erythematous mucosa from the rectum to the transverse colon. Biopsies demonstrated increased lymphocytic infiltration of the lamina propria, thickened epithelial layer and crypts with increased intraepithelial lymphocytes. Upon further questioning, the patient reported starting leflunomide 2 months prior. She was asked to trial cessation of leflunomide upon discharge. Upon 2 week follow up, diarrhea had resolved. Discussion: Leflunomide is a disease modifying drug used to treat RA among other types of inflammatory arthritis. In approximately 20% of patients, adverse gastrointestinal side effects of abdominal pain, diarrhea and nausea are well recognized. However, drug-induced colitis has only been described in a few case reports, and even fewer endoscopic descriptions exist. Paucity of this diagnosis may be attributed to its nebulous presentation. Unlike most typical drug reactions, symptom onset can range from 18-24 months. As our case exemplifies, this can lead to unnecessary testing and prolonged hospital stays. Due to this patient's symptom improvement with supportive care, we opted for drug cessation. However, for severe colitis, steroids, cholestyramine wash, and biologics may be considered.

A DOUBLE HIT: EMERGENT GUILLOTINE AMPUTATIONS DUE TO TOXIC SHOCK SYNDROME ASSOCIATED NECROTIZING FASCIITIS IN THE SETTING OF A VAGINAL CONTRACEPTIVE DEVICE AND PHARYNGITIS

A DOUBLE HIT: EMERGENT GUILLOTINE AMPUTATIONS DUE TO TOXIC SHOCK SYNDROME ASSOCIATED NECROTIZING FASCIITIS IN THE SETTING OF A VAGINAL CONTRACEPTIVE DEVICE AND PHARYNGITIS

37-Year-Old Man With Headache and Nasal Congestion

37-Year-Old Man With Headache and Nasal Congestion

57-Year-Old Man With Headache, Vomiting, and Gait Instability

57-Year-Old Man With Headache, Vomiting, and Gait Instability

De Novo Diagnosis of Lymphocytic Colitis After SARS-CoV-2 Vaccination

ABSTRACTSARS-CoV-2 mRNA vaccines are safe and effective for most patients. Gastrointestinal complications reported after vaccination have included gastroparesis and inflammatory bowel disease flares. In this study, we present a unique case of lymphocytic colitis that occurred in a healthy middle-aged man after Moderna SARS-CoV-2 mRNA vaccination. This reveals an unexpected complication of a mRNA vaccine that presented as worsening diarrhea after vaccination in a dose-dependent pattern. Caregivers should be aware of lymphocytic colitis as a possible complication of the Moderna vaccine and monitor those patients closely for symptom resolution.