Uncommon Cause Research Articles

Novel missense mutation in NKX2.6 gene (c.389 G > C, Arg130Pro) as a potentially pathogenic variant in pediatric patients with congenital heart disease

Congenital heart diseases (CHD) are the most common anomalies that occur during heart embryogenesis and are associated with significant mortality and morbidity in infants. It has been found that genomic alterations in cardiac-specific transcription factor genes play an important role in the pathogenesis of CHD. However, the prevalence of point mutations in these genes has not yet been determined. The aim of this research was to investigate the relationship of NKX2.6 gene mutations as a candidate gene in patients with congenital heart diseases. In the present study, two coding exons and flanking introns of the NKX2.6 gene, encoding a homeodomain-containing transcription factor, were sequenced in a cohort of patients. Five heterozygous NKX2.6 missense mutations, Ser37Cys, Glu54Val, Ala129Glu, Arg130Pro, Ser232Thr, and a synonymous variation, Asp68Asp, were identified in patients. They were not observed in controls, and the altered amino acids were evolutionarily highly conserved across species. The structural and functional consequences of missense mutations were assessed using various prediction servers. The consensus results showed that the Arg130Pro mutation is pathogenic/deleterious and likely to significantly affect protein function. To our knowledge, this is the first study on the association of NKX2.6 missense mutations with susceptibility to CHD in Iranian patients; our results present the spectrum of NKX2.6 mutations associated with patients and suggest that these missense mutations could be important as an uncommon cause of CHD.

Management of cerebral venous thrombosis in Spain: MOTIVATE descriptive study

IntroductionCerebral venous thrombosis (CVT) is an uncommon cause of stroke that mainly affects young adults. Early, accurate diagnosis can reduce the rate and severity of complications. ObjectiveThe aim of this study was to analyse the clinical characteristics, management, and treatment of CVT in different centres in Spain. MethodsWe conducted a multicentre, retrospective, descriptive study of patients hospitalised due to CVT between 2008 and 2017 at 10 Spanish centres. ResultsWe included 256 patients, with a mean age (SD) of 49.8 (18.7) years; 51% of patients were women. The most frequent symptoms were headache (73%), focal deficits (50%), epileptic seizures (33%), and encephalopathy (21%). The most frequent localisations were the superior sagittal sinus (12.5%), the transverse sinus (10.9%), and 2 or more sinuses or veins (66.4%). Thrombophilia was the most frequent known aetiology (24%), and was most commonly associated with the prothrombin G20210A mutation (19%). Forty-six percent of patients were treated with antithrombotics for 3 to 6 months, 21% for one year, and 22.6% required indefinite anticoagulation. Endovascular therapy was performed in 5% of cases, and 33% required neurosurgery. Regarding outcomes, 75% of patients were independent at 3 months (modified Rankin Scale [mRS] score ≤ 2), with papilloedema (P = .03), focal deficits (P = .001), and encephalopathy (P < .001) showing a statistically significant association with poor prognosis (mRS > 3). The in-hospital mortality rate was 4.3%, with a 3-month mortality rate of 6.3%. ConclusionThe diverse risk factors and variable presentation of CVT represent a challenge in the diagnosis and treatment of this condition. To improve prognosis and reduce mortality, it is essential to establish management protocols for this entity.

Characteristics of cerebral venous thrombosis in patients from two university hospitals in Colombia between 2018-2020

Describir las características clínicas, demográficas y radiológicas, y los factores de riesgo de una serie de pacientes con trombosis venosa cerebral de dos hospitales de Colombia. Materiales y métodos. Es un estudio descriptivo retrospectivo de pacientes hospitalizados, atendidos en el servicio de neurología de dos hospitales de Bogotá desde diciembre de 2018 hasta diciembre del 2020. Se incluyeron 33 pacientes. Las frecuencias más altas correspondieron a mujeres en edad fértil, en puerperio (n=7; 33,3 %) y pacientes con patologías autoinmunes (n=10; 30,3 %). El síntoma inicial más común fue la cefalea (n=31; 93,9 %), seguido de focalización neurológica (n=9; 27,2%) y crisis epiléptica (n=8; 24,2 %). El 51 % (n=17) de los pacientes tuvo un examen físico normal. El infarto venoso cerebral se presentó en el 21,1 % (n=7), la hemorragia subaracnoidea en el 12,1 % (n=4) y el hematoma intraparenquimatoso en el 9 % (n=3) del total de pacientes. El 60,6 % (n=20) quedó con nivel independiente en la escala funcional de Barthel. Ningún paciente falleció. Se encontraron características sociodemográficas, clínicas y radiológicas similares a lo reportado en la literatura mundial. Con respecto a las diferencias, se encontró en nuestro estudio compromiso de la circulación venosa cerebral profunda en un porcentaje ligeramente mayor a lo descrito, pero sin aumento de complicaciones, ni mortalidad.

Superior Mesenteric Artery Syndrome as an Atypical Aetiology of Upper Intestinal Obstruction in a Young Adult

Superior mesenteric artery (SMA) syndrome is an uncommon cause of proximal intestinal obstruction in young adults. Weight loss is one of the most significant aetiology of this condition. In young patients presenting with post-prandial abdominal pain, abdominal distension, nausea, anorexia and voluminous vomiting, the diagnosis of superior mesenteric artery syndrome should be considered. These symptoms are due to compression of the third part of the duodenum against the aorta by the overlying superior mesenteric artery. Computed tomography (CT) angiography of the abdomen is currently favoured in the literature to establish the diagnosis. We report a case of SMA syndrome in a 20-year-old Malay gentleman with a history of significant weight loss and kratom abuse for a year. A CT scan of the abdomen was performed and established the diagnosis. This patient responded to conservative treatment of nutritional supplementation.

Pleuroperitoneal communication-associated pleuritis as an uncommon cause of fever of unknown origin in a child on peritoneal dialysis: a case report

Pleuroperitoneal communication (PPC) is a rare mechanical complication of peritoneal dialysis (PD), which causes dialysate to move from the peritoneal cavity to the pleural cavity, resulting in pleural effusion. Typically, PPC is discovered through pleural effusion in PD patients who are not in volume overload status. A unique characteristic of the pleural effusion caused by PPC is that it is not resolved by increasing ultrafiltration by dialysis. In this report, we present a 7-year-old girl with PD after birth with the history of various infectious PD-related complications, presenting with fever ongoing for 6 months. PPC-associated pleuritis was suspected as the cause of fever, which eventually developed after long-term PD and induced complicated pleural effusion, lung inflammation, and prolonged fever for 6 months.

Spontaneous coronary artery dissection in women with acute myocardial infarction: is there a new role for autoimmunity?

Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute myocardial infarction in women and has an unclear pathophysiology. Autoantibodies (AAs) targeting angiotensin-II receptor type 1 (AT1R) and endothelin-1 receptor type A (ETAR) have known detrimental effects on endothelial function. We investigated the prevalence of these AAs in SCAD-affected female patients. Female patients diagnosed at coronary angiography with myocardial infarction and SCAD were consecutively enrolled. Autoantibodies targeting angiotensin-II receptor type 1 and ETAR-AA titres and seropositivity prevalence were compared between SCAD patients, ST-elevation myocardial infarction (STEMI) patients, and healthy women. Ten women with SCAD and 20 age-matched controls (10 women with STEMI and 10 healthy women) were included. Six out of 10 (60%) women with myocardial infarction and SCAD were seropositive for AT1R-AAs and ETAR-AAs. In contrast, only one (10%) healthy woman and one (10%) STEMI patient were seropositive for AT1R-AAs (P = 0.03 and P = 0.03, respectively). One STEMI patient was seropositive for ETAR-AAs, while none of the healthy women was found to be seropositive (P = 0.03 and P = 0.01, respectively). The median AA titre was significantly higher in SCAD patients than in healthy women (P = 0.01 for AT1R-AAs; P = 0.02 for ETAR-AAs) and STEMI patients (P < 0.001 for AT1R-AAs; P = 0.002 for ETAR-AAs). Autoantibodies targeting angiotensin-II receptor type 1 and ETAR-AA seropositivity is significantly higher in SCAD women with myocardial infarction than in healthy women or female patients with STEMI. Our findings, corroborated by previous data in the literature and biological plausibility, suggest a possible role for AT1R-AAs and ETAR-AAs in the pathophysiology of SCAD in women with acute myocardial infarction and should warrant further studies with larger sample sizes.

BH11 Cutis verticis gyrata associated with chronic traction

Abstract Cutis verticis gyrata (CVG) is a rare condition characterized by overgrowth of the skin of the scalp, leading to skinfolds and deep convoluted furrows that resemble the cerebral cortex gyri. Cases of CVG have been classified into primary essential, primary nonessential and secondary. Primary essential CVG has no associated abnormalities. Primary nonessential CVG is associated with neurological or ophthalmological abnormalities. Secondary CVG is due to a local inflammatory or neoplastic process, or an underlying endocrine or genetic cause. We present two cases of CVG associated with chronic traction alopecia. The main clinical features in both cases were thickened skinfolds in the central scalp, which did not extend to the lateral scalp, recession of the frontal hairline with fringe sign and a negative hair-pull test. Histological findings from the zone of alopecia included nonscarring hair loss with the presence of fibrous tracks within the skin but preservation of the sebaceous glands, consistent with chronic traction alopecia. Both patients were advised to reduce tension on the hair and were treated with topical minoxidil and advised on hair transplantation. Patient 1 was a 15-year-old Sikh boy who developed CVG secondary to chronic traction applied from tying his hair at the top of his scalp when wearing a turban. Owing to cultural practices, the patient could not cut his hair, representing a challenge of treating CVG associated with chronic traction in this group of patients. Patient 2 was a 16-year-old girl with a background of joint hypermobility and recurrent hip dislocations, currently undergoing genetic testing for Ehlers-Danlos syndrome. She developed CVG following chronic traction due to hairstyling. Interestingly, cutting her hair resulted in some improvement of the appearance of CVG, possibly due to reduced hair tension. Chronic traction is an uncommon cause of CVG, with only a few cases reported in the literature. It is likely that the persistent tension of tight hairstyles pulls the scalp into folds and contributes to the appearance of CVG. These cases highlight the importance of ascertaining whether a history of traction styling is present in the diagnosis and management of CVG.

Left Laparoscopic Transperitoneal Adrenalectomy for Aldosteronoma

Primary hyperaldosteronism refers to the autonomous secretion of the hormone aldosterone from the adrenal gland, resulting in low renin levels. This usually occurs in individuals between the ages of 30 to 50 years old. The majority of these cases are caused either by a solitary, functioning adrenal adenoma or aldosteronoma (70%) or by idiopathic bilateral hyperplasia (30%). Other uncommon causes include adrenal carcinoma and familial hyperaldosteronism. Patients typically present with hypokalemia and long-standing hypertension that is difficult to control despite multi-drug therapy; nevertheless, further tests are required for diagnosis. An elevated plasma aldosterone level with a suppressed plasma renin level is strongly suggestive of the diagnosis. Once confirmed, further evaluation should be directed toward determining if the cause is a unilateral aldosteronoma or bilateral adrenal hyperplasia. This is done through imaging studies and adrenal vein sampling. Unilateral aldosteronoma is best managed by adrenalectomy, with the laparoscopic approach being the preferred method. Bilateral adrenal hyperplasia is often best treated medically, because only 20%–30% benefit from surgery. Here, we present the case of a 48-year-old woman who had long-standing hypertension and hypokalemia and was found to have hyperaldosteronism and low renin levels. A CT scan showed a small mass in the left adrenal gland, and adrenal vein sampling showed higher levels of aldosterone on the left side than on the right, confirming a unilateral aldosteronoma. Laparoscopic access was gained, the adrenal gland was exposed, dissected by controlling the periadrenal tissues with the harmonic scalpel, the adrenal vein was then ligated, and the adrenal gland was removed.

Legionella associated rhabdomyolysis: a case report

BackgroundInfections have been recognized as an uncommon cause of rhabdomyolysis, with evidence indicating a worse prognosis when compared to rhabdomyolysis caused by other etiologies. Diseases caused by Legionella pneumophila can present variably, ranging from mild to severe illness, as is sometimes the case with pneumonia. In particular, the triad of Legionnaire’s disease, rhabdomyolysis, and acute kidney injury is associated with a significant increase in the morbidity and mortality, with most patients requiring initiation of renal replacement therapy such as hemodialysis. While the exact mechanism of both the muscle and kidney injury in this setting remains unknown, several hypotheses exist, with some research suggesting multiple yet distinct processes occurring in both target organs.Case presentationIn this case report, we describe a 53-year-old African American man who presented with Legionella pneumophila pneumonia complicated by rhabdomyolysis and acute kidney injury. He was treated with aggressive fluid resuscitation and a 2-week course of azithromycin. His clinical status improved without necessitating renal replacement therapy or mechanical ventilation. We postulate that early recognition and treatment were key to his recovery. He was discharged 10 days later without recurrence of rhabdomyolysis at the time of this report.ConclusionWhile there are several well-established and more common causes of rhabdomyolysis, clinicians should recognize Legionella sp. as an etiology, given its association with significant morbidity and mortality.

Cough RIB Fracture: An Uncommon Upper Respiratory Cause.

Cough is a whole-sole dynamic housekeeper of the airways. Although a run-of-the-mill symptom, chronic cough frequently forces the patient to seek medical help. It can persist for years end on, and not only makes the patient anxious about underlying illness, but may cause vomiting, exhaustion, impaired sleep, urinary incontinence, and social embarrassment. The propulsive effort made by the patient to clear the noxious stimuli irritating the airways can at times disrupt the integrity of the chest wall and result in rib fractures. We present a case who was detected to have cough fracture during the evaluation of symptoms of chronic cough with pleuritic chest pain. He was evaluated for the aetiology of chronic cough and was diagnosed to have laryngopharyngeal reflux which even though a common aetiology for chronic cough is a very uncommon cause of cough rib fracture. The importance of small innocuous diseases causing severe debility, even in patients with no comorbid illness or contributing risk factors is emphasized by this case report.

A rare presentation of idiopathic distal radial artery aneurysm in anatomical snuff box in a 40 year old male

True non- traumatic radial artery aneurysms (RAAs) are uncommon; just a small number of cases have been reported. The majority are iatrogenic pseudo-aneurysms caused by arterial cannulation and have traumatic origins. There have also been reports of other uncommon causes include vascular tumors

Beyond Alcohol and Gallstones: Uncommon Causes of Pancreatitis

Pancreatitis is a major cause of hospital admissions with significant associated morbidity and mortality. Global incidence rates have continued to increase over the last several decades with United States leading the Western world. The most common causes include gallstones for acute pancreatitis and alcohol abuse for both chronic and acute pancreatitis; these are well described in the literature and not infrequently encountered in the day-to-day practice of radiology. Several uncommon pancreatitis causes have unique characteristic patient demographics, clinical presentations, and imaging findings. The unique features relevant to the practice of radiology are discussed for autoimmune pancreatitis, groove pancreatitis, tropical pancreatitis, hereditary pancreatitis, and pancreatic adenocarcinoma presenting as acute pancreatitis with companion cases. The differentiating features of these uncommon causes are emphasized to arrive at a diagnosis. Should imaging remain equivocal, the next steps necessary to arrive at a diagnosis are reviewed. Understanding the various presentations of acute and chronic pancreatitis, both uncommon and common causes are of utmost importance for the practicing radiologist in facilitating management of patient care.

P24 Auditing antibiotic course lengths for the management of community-acquired pneumonia and hospital-acquired pneumonia against current NICE guidance

Abstract Background Protracted antibiotic course lengths for the treatment of community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP) contribute to increased risk of antibiotic resistance.1 Optimizing antibiotic course length in line with the current national guidance improves patient safety and overall cost savings.1 NICE guidelines state that antibiotic treatment should be stopped at day 5 if patients were afebrile for &amp;lt;48 hours with one or no sign of clinical instability, defined as systolic blood pressure &amp;lt; 90 mmHg, heart rate &amp;gt; 100/minute, respiratory rate &amp;gt; 24/minute, arterial oxygen saturation &amp;lt; 90% or oxygen partial pressure &amp;gt; 60 mmHg in room air.2 Objectives To assess the current prescribing practice for antibiotic course lengths of CAP and HAP across medical specialties at RCHT. Methods A list of patients discharged from medical specialities (respiratory, cardiology, nephrology, gastroenterology, endocrinology and geriatrics) between 1 August and 1 September 2022 with the coded indication of CAP or HAP was requested from the RCHT Informatics Team. Inclusion criteria were any hospitalized patient aged ≥18 years, with a CAP/HAP diagnosis with pulmonary infiltrate on chest X-ray plus at least one symptom including cough, fever, dyspnoea and chest pain. Patients were excluded if having chronic immunosuppression; HIV positive; living in a nursing/care home, onsite subacute care unit or intensive therapy unit (ITU) or palliative care unit within last 14 days; having taken antibiotics 30 days before admission; requiring a longer duration of therapy because of an uncommon cause; requiring a chest tube or having had a condition complicated by extrapulmonary infection.1 For each patient, the patient’s vital signs at day 5 of antibiotic course and the total antibiotic course lengths were recorded. Results A total of 27 patients were assessed for eligibility; of these, 22 patients (81%) met the inclusion criteria, and 5 patients were excluded. Among those excluded, two recently stepped down from ITU, two lived in a nursing/care home and one had taken antibiotics 30 days before admission. Of the 22 patients, 10 patients (45%) received 5 or 6 days of antibiotics for CAP/HAP. The remaining 12 patients (55%) received courses between 7 to 10 days despite meeting the criteria for stopping antibiotics at 5 days. The mean and median of antibiotic course length including all specialities were 6.5 and 6.3 days, respectively. Conclusions This audit demonstrates that almost half of patients with CAP /HAP are being managed with antibiotic courses of fewer than 7 days. Further prescriber and pharmacy team education sessions on appropriate course lengths are needed. There is consideration for an alert notification on EPMA which reminds prescribers to check patient’s vital signs on day 5 when prescribed an antibiotic for the treatment of CAP and HAP. Recommendation would be to reaudit with a longer data collection timeframe and larger sample size.

Lingual abscess, an uncommon cause of tongue oedema: Case series

Lingual abscess is a rare but potentially life-threatening medical entity. Consequently, it requires high medical suspicion in order to prevent misdiagnosis. Unilateral tongue oedema constitutes the characteristic clinical feature.

Synovial cysts at the cervicothoracic junction: Illustrative series of three cases.

Spinal synovial cysts are an uncommon pathology, estimated to affect 0.65-2.6% of the population. Cervical spinal synovial cysts are even rarer, accounting for only 2.6% of spinal synovial cysts. They are more commonly found in the lumbar spine. When they occur, they can compress the spinal cord or surrounding nerve roots resulting in neurological symptoms, particularly when they increase in size. Decompression and cyst resection are the most common treatment and typically result in resolution of symptoms. The authors present three cases of spinal synovial cysts occurring at the C7-T1 junction. They occurred in patients aged 47, 56, and 74, respectively, and presented with symptoms of pain and radiculopathy. Diagnosis was made with computed tomography (CT) scan and magnetic resonance imaging (MRI). The cysts were managed with laminectomy, resection, and fusion. All patients reported full resolution of symptoms. There were no intra or postoperative complications. Cervical spinal synovial cysts are an uncommon cause of radiculopathy and pain in the upper extremities. They can be diagnosed through CT scans and MRI, and treatment with laminectomy, resection, and fusion results in excellent outcomes.

Recurrent Membranoproliferative Glomerulonephritis After Kidney Transplantation: Risk Factors and Impact on Graft Survival.

BACKGROUND Membranoproliferative glomerulonephritis (MPGN) is an uncommon cause of end-stage renal disease (ESRD). Recurrence rates after transplantation range from 11.8% to 18.9% after 5 and 15 years, respectively. This study aimed to assess the risk factors of MPGN recurrence after kidney transplantation and its impact on graft survival. MATERIAL AND METHODS This was a single-center retrospective cohort, including renal transplant recipients older than 18 years, with a diagnosis of MPGN in native kidneys. Data were obtained from medical records during the first 5-year post-transplant follow-up. Primary endpoints were graft function and survival. Secondary endpoints were MPGN recurrence risk factors and these cases' clinical, laboratory, and histological features. RESULTS Twenty-eight patients were included; the majority male (60.7%), with a mean age of 24.0±9.4 years. At MPGN native diagnosis, all patients presented proteinuria, with C3 consumption in 42.9%. Histological analysis showed 13 (42.9%) MPGN type I and 5 (17.9%) type II, with no cases of type III. MPGN recurrence occurred in 7 (25.0%) patients; 85.7% were male, 57.1% were recipients from a living donor, all presenting nephrotic syndrome and hematuria, with C3 consumption in 71.4%. The graft function was similar between the groups. Two (28.6%) patients progressed to graft failure in the recurrence group, and 1 died with a functioning graft. CONCLUSIONS The MPGN recurrence rate was 25%, most of them recipients of kidneys from living donors. Nephrotic syndrome and C3 consumption were frequent at recurrence. The graft function was similar between the groups, and the 5-year graft survival rate in the recurrence group was higher than in other studies.

Mediastinal parathyroid carcinoma: a case report and review of the literature

BackgroundParathyroid carcinoma (PC) is an uncommon cause of primary hyperparathyroidism (PHPT) and particularly rare in the mediastinum. Herein, we present a case of mediastinal PC and conduct a related literature review.Case presentationWe described a case of a 50-year-old female patient with PHPT due to mediastinal PC. She was initially admitted to a local hospital in her hometown with hypercalcemia and high blood concentrations of PTH (parathyroid hormone). The patient underwent neck parathyroidectomy and pathological examination suggested parathyroid adenoma. Although the overproduction of serum calcium and PTH declined after the surgery, calcium and PTH increased again one month later, so the patient was transferred to our hospital. A 99mTc-sestamibi scan revealed an ectopic finding in the mediastinum, which was also indicated on the CT image. After removing the mediastinal mass, the metabolism of calcium and PTH quickly reverted to normal and the pathologic features of the mass were consistent with PC. By reviewing the related literature, we noticed that only scattered reports were published before 1982, and those were not included in the present review due to their differences with current radiological examination and treatment methods. After excluding outdated studies, we summarized and analyzed 20 reports of isolated mediastinal PC and concluded that. Parathyroidectomy remains the only curative treatment for the disease. Furthermore, the success of treatment directly depends on accurate preoperative localization.ConclusionWith this study, we emphasize the importance of accurate preoperative diagnosis of mediastinal PC and improve clinicians’ understanding of the disease.

Atypical Ovarian Tumor: Mixed Sertoli–Leydig Cell Tumor of Retiform Variant with Focal Heterologous Elements

ABSTRACT Ovarian torsion is an uncommon cause for acute abdominal pain in children while the possibility of malignancy presenting as ovarian torsion is even rarer. We report here an atypical case of ovarian neoplasm presenting as ovarian torsion in a 5-year-old child. The highlight of this case is the epithelial component staining positive for both CK 7 and CK 20 in addition to Sertoli–Leydig cell component indicating it as mixed Sertoli–Leydig cell tumor of retiform variant with focal heterologous elements. The heterologous element is the CK7 and 20 being positive epithelium. The ovarian torsion should make one suspect malignancy in and around the ovary and subject it for detailed histopathologic study and manage accordingly; lest, one’s failure to suspect the same may compromise patient management and prognosis.

Nontyphoidal Salmonella Invasive Disease: Challenges and Solutions.

Nontyphoidal Salmonella are a leading cause of community-onset bacteremia and other serious infections in sub-Saharan African countries where large studies indicate that they are an uncommon cause of moderate-to-severe diarrhea. Approximately 535 000 nontyphoidal Salmonella invasive disease illnesses and 77 500 deaths were estimated to occur in 2017; 422 000 (78.9%) illnesses and 66 500 (85.9%) deaths in countries in sub-Saharan Africa. Lineages of Salmonella enterica serovar Typhimurium sequence type (ST) 313 and lineages of Salmonella enterica serovar Enteritidis ST11 dominate as causes of invasive disease. A major reservoir for these specific strains outside of humans has not been identified to date. Human fecal shedding of such strains is common in areas where nontyphoidal Salmonella invasive disease incidence is high. The case-fatality ratio of nontyphoidal Salmonella invasive disease is approximately 15%. Early diagnosis and treatment are needed to avert fatal outcomes. Antimicrobial resistance, including multiple drug resistance, decreased fluoroquinolone susceptibility, and resistance to third-generation cephalosporins, is increasing in prevalence and is likely to further compromise patient outcomes. Naturally acquired immunity against invasive disease develops in children aged >3 years in endemic areas, likely mediated in part by the sequential acquisition of T-cell immunity, followed by antigen-specific immunoglobulin G antibodies. Vaccines in preclinical or clinical development include live-attenuated S. enterica serovar Typhimurium, nontyphoidal S. enterica core and O-polysaccharide glycoconjugates, multiple antigen-presenting system complexes, and generalized modules for membrane antigens vaccines. The latter are in phase I trials in Europe and Africa. Both vaccine use, and other effective, evidence-based nonvaccine interventions, are needed to prevent and control nontyphoidal Salmonella invasive disease.

Multiple Gastric Dieulafoy Lesions

ABSTRACT Dieulafoy lesions (DLs) are an uncommon nonvariceal cause of gastrointestinal bleeding. Although advanced endoscopic treatment is successful in majority, rarely radiologic intervention or surgery may be needed. Most of the reported case series described single DLs, and very limited data were available about multiple or synchronous DLs. We report a rare case of multiple DLs of the stomach refractory to repeated endoscopic interventions by hemoclips, regional diluted adrenaline injections, hemospray, and argon photocoagulation therapies and requiring total gastrectomy and roux-en-y esophagoduodenostomy surgery.