White Exudates Research Articles

Ankylosaurus back sign: novel endoscopic finding in esophageal eosinophilia patients indicating proton pump inhibitor response

Background and study aims Characteristic endoscopic findings, such as linear furrows, rings, and whitish exudates, indicate the presence of esophageal eosinophilia (EE), though no specific findings are known to distinguish eosinophilic esophagitis (EoE) from proton pump inhibitor-responsive esophageal eosinophilia (PPI-REE). Here, we present a novel endoscopic finding in some EE patients possessing a linear longitudinal arrangement of whitish nodules with the appearance of the back of an Ankylosaurus dinosaur, termed Ankylosaurus back sign (ABS), and evaluations of its significance in affected patients. Patients and methods Fifty-five patients diagnosed with EE (≥ 15 eosinophils/high power field) who were treated at our hospital and shown to evaluate a PPI response were enrolled. Endoscopic findings at baseline and clinical parameters were retrospectively reviewed. Furthermore, the clinicopathological features of patients with ABS, as well as the relationship between its presence and PPI response were evaluated. Results Fifty-five patients (47 males, 8 females) with EE (17 with EoE, 38 with PPI-REE) were evaluated, of whom 50 (90.9 %) had linear furrows, the most frequently found feature, while ABS was found in 9 (16.4 %). Inter-observer agreement was substantial for ABS (κ 0.77). Interestingly, all patients with ABS had PPI-REE. Our findings revealed that the presence of ABS was closely associated with reflux esophagitis (RE) in patients with PPI-REE. Conclusions Although ABS was less frequent than typical endoscopic findings such as linear furrows in EE, this novel finding was closely associated with PPI-REE accompanied with RE. The clinical implications of ABS in patients with EE should be investigated further.

First Report of Bionectria pseudochroleuca Causing Dieback and Wilting on Avocado in the Serrania de Perijá, Colombia

HomePlant DiseaseVol. 102, No. 1First Report of Bionectria pseudochroleuca Causing Dieback and Wilting on Avocado in the Serrania de Perijá, Colombia PreviousNext DISEASE NOTES OPENOpen Access licenseFirst Report of Bionectria pseudochroleuca Causing Dieback and Wilting on Avocado in the Serrania de Perijá, ColombiaO. Burbano-Figueroa, A. Arcila, A. M. Vasquez, F. Carrascal, K. Salazar Pertuz, M. Moreno-Moran, J. Romero-Ferrer, and J. A. PulgarinO. Burbano-Figueroa†Corresponding author: O. Burbano-Figueroa; E-mail: E-mail Address: alephxv@gmail.comSearch for more papers by this author, A. ArcilaSearch for more papers by this author, A. M. VasquezSearch for more papers by this author, F. CarrascalSearch for more papers by this author, K. Salazar PertuzSearch for more papers by this author, M. Moreno-MoranSearch for more papers by this author, J. Romero-FerrerSearch for more papers by this author, and J. A. PulgarinSearch for more papers by this authorAffiliationsAuthors and Affiliations O. Burbano-Figueroa † , The Plant Interactions Laboratory, Turipaná Research Center, Corporación Colombiana de Investigación Agropecuaria (CORPOICA), Cereté, 230558, Córdoba, Colombia A. Arcila , Entomology Laboratory, Caribia Research Center, Corporación Colombiana de Investigación Agropecuaria (CORPOICA), Zona Bananera, 478029, Magdalena, Colombia A. M. Vasquez , The Plant Interactions Laboratory, Turipaná Research Center, Corporación Colombiana de Investigación Agropecuaria (CORPOICA), Cereté, 230558, Córdoba, Colombia F. Carrascal , Entomology Laboratory, Caribia Research Center, Corporación Colombiana de Investigación Agropecuaria (CORPOICA), Zona Bananera, 478029, Magdalena, Colombia K. Salazar Pertuz M. Moreno-Moran J. Romero-Ferrer , The Plant Interactions Laboratory – Plant Physiology Laboratory, Turipaná Research Center, Corporación Colombiana de Investigación Agropecuaria (CORPOICA), Cereté, 230558, Córdoba, Colombia J. A. Pulgarin , Entomology Laboratory, El Nus Research Center, Corporación Colombiana de Investigación Agropecuaria (CORPOICA), San Roque, 053037, Antioquia, Colombia. Published Online:27 Oct 2017https://doi.org/10.1094/PDIS-01-17-0010-PDNAboutSectionsSupplemental ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InRedditEmailWechat Symbioses among ambrosia beetles and fungi are one of most common and successful relationships in any forest ecosystem. Ambrosia beetle–fungus interactions with trees are typically benign, and only dead or stressed trees are susceptible to be colonized. In recent decades, many of these relationships transformed into unexpectedly destructive tree diseases, especially when they challenge a new noncoevolved host (Kasson et al. 2013; Ploetz et al. 2013). Tree colonization by xylomicetophagous Scolytinae and its ambrosia fungi provoking branch dieback, wilting, and mortality have been reported in avocado-growing regions around the world (Freeman et al. 2013). Some ambrosia fungi can be laterally transferred by several species of xylomicetophagous beetles, increasing their host range and spatial distribution (Carrillo et al. 2014). During the 2013–14 dry and rainy seasons, avocado trees exhibiting branch dieback and wilting were observed in San Diego, La Paz, and Jagua del Pilar municipalities located in the Serrania de Perija mountain range. Close examination revealed white powdery exudate over the outer bark associated with beetle holes on the trunk and main branches of avocado trees. Old trees (>15 m height) exhibited black exudate extensively covering the whole trunk (black gum pitchout). Wood under the exit hole revealed brown necrosis. Adults and larvae of ambrosia beetles (Xyleborus volvolus and Premnobius spp.) were found within galleries. Sapwood tissues were plated onto V8 agar amended with amikacin sulfate (0.1 g/liter). After 1 week incubation, white flat filamentous fungal colonies with filiform margin and aseptate hyphae were observed. Conidia were hyaline, short, aseptate, straight-cylindrical, and rounded at both ends. To confirm identity, partial sequencing of the β-tubulin (TUB) gene from three isolates (TUR5.159, TUR5.192, and TUR5.181) was performed. Sequences were deposited into GenBank (KX981917, KX827304, and KX827303). A BLASTn search revealed high similarity (>97%) to Bionectria pseudochroleuca strain CML 2526 (accession no. KX185045.1). Ten additional ID loci were included but PCR amplifications were not successful. Healthy 6-month-old avocado trees were wounded to a depth of 3 to 5 mm and 5-mm mycelial plugs from 5-day-old cultures were placed onto the freshly wounded surfaces and then wrapped with Parafilm. Control shoots were inoculated with sterile agar plugs and three replicates per isolate were used. Expanding lesions were observed on all inoculated plantlets except for the control (lesions length: 4.21 ± 0.62 cm). The fungal pathogen was reisolated from lesions of inoculated avocado plantlets and the identity was confirmed through cultural characteristics and conidial morphology. Bionectria species associated with ambrosia beetles colonizing avocado trees has been reported in California (Eskalen et al. 2012; McDonald and Eskalen 2011). To our knowledge, this is the first report of a Bionectria species causing dieback and wilting on avocado in Colombia.

Icing Sugar Spleen/Perisplenitis Cartilaginea: A Case Report

Spleen, being the largest organ of the mononuclear phagocytic system is involved in many systemic inflammations, generalized haematopoietic disorders as well as metabolic disorders. Perisplinitis, also known colloquially as “icing sugar spleen”, is a common autopsy finding. The capsule of the spleen becomes nodular, thickened and fibrotic and it appears as though the spleen has been dipped in white icing. Perisplenitis is seen as creamy yellow to white exudates or firm glistening “icing-like” plaques on the capsular surface, indicating active acute or regressed infection, respectively. It is usually secondary to generalised peritonitis or extension from local infection. It has been reported as part of Curtis-Fitz-Hugh syndrome or a common accompaniment to cirrhosis of the liver. Massive splenomegaly with sugar icing spleen is also seen in chronic myeloid leukemia and may be seen in sickle cell anaemia. Here we present a case of perisplinitis in a 65 years old male patient as an incidental autopsy finding.

Challenging and uncommon diagnosis of long-evolution ascites

This is a case report of a 45-year-old Caucasian man with chronic alcoholism. No history of liver disease or asbestos exposure. He complained of ascites during the last 3 years...

Neonate with a Hypopigmented Rash

A preterm male infant in the NICU develops a rash with erythematous and hypopigmented macules, patches, and papules of the arms, axillae, neck, upper back, groin, and legs. The rash has a geometric pattern in areas of occlusion (ie, under leads and wires) and maceration with white exudate in the axillae (Fig 1). Figure 1. Erythematous and hypopigmented macules, patches, and papules of the arms, axillae, neck, upper back, groin, and legs. Note the geometric pattern in areas of occlusion (ie, under leads and wires) and maceration with white exudate in the axilla. ### Prenatal and Birth Histories ### Presentation (Day 21) At 21 days of age, the infant was in a double-walled, heated, and humidified isolette and developed the rash described before. At that time, he required nasal continuous positive airway pressure for respiratory support and was tolerating full nasogastric feedings. #### Vital Signs #### Physical Examination

Eosinophilic Enteritis: A Delayed Diagnosis

Eosinophilic Gastrointestinal Disorders (EGID) are a rare and complex group of disorders that are characterized by eosinophilic infiltration of the gastrointestinal tract. Eosinophilic esophagitis (EoE) is limited to the esophagus while eosinophilic gastroenteritis (EGE) can involve any portion of the GI tract. Patients often present with a wide range of signs and symptoms including abdominal pain, nausea, vomiting, dysphagia, diarrhea, and even more serious manifestations such as intestinal obstruction or perforation as any length or layer of the GI tract can be involved such as mucosal, muscular, or serosal1,4,10. As a part of the work-up, patients frequently undergo CT scans and multiple endoscopies before the diagnosis is finally made as was true in our case of a 59 year-old male patient presenting with 2 months of nausea, abdominal pain and weight loss. He underwent EGDs, colonoscopies, a video capsule study and balloon enteroscopy before the diagnosis was confirmed histologically. Endoscopic findings can be variable and often include mucosal erythema, edema, strictures, polypoid lesions and ulcerations8. Radiographic findings are also unpredictable and may include mural thickening, nodularity, luminal narrowing, and perienteric inflammation suggestive of an acute inflammatory condition2,3,8. The diagnosis is confirmed on histopathological examination of biopsies that must show >15-50 eosinophils/high power field based on the location in the GI tract. In our patient, erythema, scalloping, whitish exudate, and patches of villous blunting with a flat pink appearance were noted in the duodenum to proximal ileum endoscopically with >50 eosinophils/hfu confirming the diagnosis of eosinophilic enteritis. This class of diseases is often found in patients with a history of allergic disorders including asthma, eczema, seasonal allergies and food allergies suggestive of hypersensitivity in the etiology of the disease although our patient had no such known history4. Elimination diets and steroids are the mainstay of therapy and often lead to complete resolution of symptoms as well as endoscopic and radiographic findings in up to 90% of patients as was seen in our patient, although some patients have a chronic remitting course8.Figure: Endoscopy showing erythematous gastric nodules in the antrum of the stomach.Figure: Endoscopy showing erythema, scalloping, and villous blunting throughout portions of gastrointestinal tract.

Eosinophilic Enteritis: A Delayed Diagnosis.

Eosinophilic gastrointestinal disorders are a rare and complex group of disorders that are characterized by eosinophilic infiltration of the gastrointestinal tract. Patients often present with a wide range of signs and symptoms as any length or layer of the GI tract can be involved such as mucosal, muscular, or serosal. As a part of the workup, patients frequently undergo computed tomography scans and multiple endoscopies before the diagnosis is finally made as was true in our case of a 59-year-old male patient presenting with 2 months of nausea, abdominal pain, and weight loss. He underwent esophagogastroduodenoscopies, colonoscopies, video capsule study, and balloon enteroscopy before the diagnosis was confirmed histologically. Endoscopic and radiographic findings can be variable and are usually unpredictable. The diagnosis is confirmed on histopathological examination of biopsies that must show >15-50 eosinophils/high-power field based on the location in the GI tract. In our patient, erythema, scalloping, whitish exudate, and patches of villous blunting were noted in the duodenum to proximal ileum endoscopically with >50 eosinophils/high-power field confirming the diagnosis of eosinophilic enteritis. This class of diseases is often found in patients with a history of allergic disorders suggestive of hypersensitivity in the etiology of the disease although our patient had no such known history. Elimination diets and steroids are the mainstay of therapy and often lead to complete resolution of symptoms as well as endoscopic and radiographic findings in up to 90% of patients as was seen in our patient, although some patients have a chronic remitting course.

Herpes Esophagitis in an Immunocompetent Patient

HSV esophagitis is well recognized in the immunocompromised host, but can infrequently be seen in the immunocompetent. It rarely causes significant complications such as GI bleed and esophageal perforation. We report a case of an immunocompetent patient who presented with upper GI bleed and was noted to have HSV esophagitis on EGD. This is a 58 year old female with a history May-Thurner syndrome and multiple DVTs admitted for IR thrombolysis of extensive DVT. During her admission she was on aspirin, clopidogrel, and therapeutic enoxaparin. While in the hospital, she developed melena, so she was started on pantoprazole drip and GI was consulted. EGD was done and noted patches of white esophageal exudates with underlying ulcers. Biopsy results showed squamous cells with intranuclear viral type inclusions that were positive for HSV on immunochemical stain. The patient had no previous history of immunodeficiency and has not been on any steroids or other immunosuppressants. HIV screening came back negative. She was treated with acyclovir, pantoprazole and sucralfate and completed a seven day course of acyclovir as an outpatient. Herpes esophagitis in immunocompetent hosts is thought to be exceedingly rare, but may be significantly underestimated. Although typical symptoms include acute dysphagia, odynophagia, chest pain, and fever, an atypical or milder presentation is not uncommon. These patients may be treated empirically with acid suppression for GERD. Resolution of symptoms in these individuals would be expected, despite absence of antivirals, because HSV esophagitis is largely self limited in immunocompetent individuals. Therefore HSV esophagitis in the immunocompetent may be more common than we think and patients are likely going undiagnosed due to atypical presentation and self limiting disease.

Eosinophilic esophagitis in children: analysis of 22 cases

Objective: Eosinophilic esophagitis (EoE) is a chronic immune-mediated esophageal disease.The current domestic reports of EoE in children is rare.The aim of this study was to analyze the clinical features, the diagnosis and treatment advance of EoE in children by case analysis and literature review. Method: Clinical data of 22 children with EoE from January, 2011 to December, 2015 in Children's Hospital, Zhejiang University School of Medicine were recorded, retrospective analysis was performed on clinical presentation, gastroendoscopy and histopathological examination features and the treatment. Result: (1) Clinical data: EoE can occur at any age in children (5 months to 13 years). The most common clinical manifestations of EoE are vomiting and abdominal pain, 45% (10/22) and 41%(9/22) respectively. (2) Endoscopy and pathological features of esophageal mucosa: 11 cases with coarse mucous membrane (50%), 6 cases with congestion or erosion of esophageal membrane (27%), 5 cases with longitudinal crack (23%), 3 cases with ring uplift (14%), 3 cases with granular uplift (14%), 3 cases with normal mucosa(14%). Histopathologic manifestation is eosinophil infiltration and the eosinophil counts were all more than or equal to 15/HP. (3) Laboratory results: 13 cases had increasing eosinophil counts and eosinophils proportion (62%). (4)Allergy history: among 22 cases, 7 patients had allergy history (32%). (5) Situation of treatment and remission: 16 cases had clinical remission by oral omeprazole; 2 cases had clinical remission by oral Omeprazole and Montelukast sodium; 1 case acquired remission by elimination diet; 1 case acquired remission by elimination diet and oral prednisone. 2 cases dropped out; Only 2 patients received gastroendoscopy re-examination after 3 months and revealed esophageal mucosal histologic complete recovery. Conclusion: The clinical symptoms of EoE in children varies.Esophageal mucosal features of gastroendoscopy examination in children with EoE were longitudinal crack, white exudates or plaques, paper mucosa, ring uplift and granular uplift.Most patients could achieve remission by using proton-pump inhibitors, only few children needed elimination diet and change formula, or even oral glucocorticoids.

High-definition-iSCAN virtual chromoendoscopy has high sensitivity and specificity for the diagnosis of eosinophilic esophagitis.

Abstract Background and study aims A major challenge in eosinophilic esophagitis (EoE) is disease recognition during endoscopy as there are no pathognomonic findings. We aimed to determine the utility of high-definition (HD) iSCAN virtual chromoendoscopy (VC) in diagnosis of EoE. Patients and methods One hundred eighty-nine consecutive patients presenting with dysphagia or food bolus impaction were assessed using HD-iSCAN VC (Pentax, Japan) with biopsies from distal, mid, upper esophagus and from furrows where visible. Results Of 189 patients, 45 (23.8 %, male = 29, median age 40y) had a histological diagnosis of EoE; 73.3 % of the patients were newly diagnosed. iSCAN endoscopic features of EoE were linear furrows (91 %), edema (77.8 %), rings or tracheal appearance (73.3 %), whitish exudates (26.6 %) and narrowing or stricture (5 %). One patient (2.2 %) had all 5 endoscopic features. Ten patients (22.2 %) had linear furrows, edema,rings or tracheal appearance and whitish exudates on iSCAN, with a positive predictive value (PPV) 100 % (95 % CI 69.1 %-100 %) and negative predictive value (NPV) 80.4 % (95 % CI 73.9 %-86 %). Thirteen patients (29 %) presented with linear furrows, edema and rings or tracheal appearance on iSCAN, with a PPV 100 % (95 % CI 75.3 %-100 %) and NPV 81.8 % (95 % CI 75.3 %-87.2 %). Six patients (13.3 %) had furrows and edema and 6 patients (13.3 %) had furrows and rings or tracheal appearance on iSCAN, with a PPV 100 % (95 % CI 54.1 %-100 %) and NPV 78.69 % (95 % CI 72 %-84.4 %), respectively. The sensitivity and specificity of HD-iSCAN endoscopy were 97.62 % (95 % CI 87.43 %-99.94 %) and 89.58 % (95 % CI 83.40 %-94.05 %). The accuracy of HD-iSCAN endoscopy was 92.47 % (95 % CI 87.67 %-95.56 %). Conclusion HD-iSCAN endoscopy is sensitive and specific with good accuracy for EoE diagnosis. Linear furrows, edema and tracheal appearance were the most common findings and these 3 endoscopic features had a high predictive value for diagnosis of EoE.

Poor inter-observer agreement on the endoscopic diagnosis of eosinophilic esophagitis among Japanese endoscopists

A variety of endoscopic findings are considered useful for the diagnosis of eosinophilic esophagitis (EoE). However, the diagnostic consistency among Japanese endoscopists for those findings has not been fully examined. The aim of this study was to investigate the inter- and intra-observer agreement for endoscopic findings suggesting EoE. Forty endoscopists, including 20 with board certification from the Japan Gastroenterological Endoscopy Society (JGES), participated in this study. Initially, they examined 50 randomized white-light endoscopic images from 30 patients with EoE and 20 without EoE. Four weeks later, the same 50 endoscopic images were re-examined in a different random order. Inter- and intra-observer agreement was calculated using kappa statistics for multiple observers. The kappa coefficient of reliability [95% confidence interval (CI)] for all 40 endoscopists for diagnosis of EoE was 0.34 (0.33–0.35), indicating poor level of inter-observer agreement, while intra-observer agreement showed a moderate value of 0.52 (0.47–0.57). Among 4 possible endoscopic findings (linear furrows, concentric rings, edema, white exudates) for EoE, acceptable levels (kappa value >0.4) of inter- and intra-observer agreement were seen only for linear furrows. When the JGES board-certified and non-certified endoscopists were compared for successful diagnosis of EoE, the value was significantly higher for the board-certified group. However, the level of inter-observer agreement remained poor level. We concluded that inter-observer agreement on the endoscopic diagnosis of EoE among Japanese endoscopists did not reach a clinically acceptable level.

Nasal, oral, and pharyngolaryngeal manifestations of pemphigus vulgaris: Endoscopic ororhinolaryngologic examination.

Pemphigus vulgaris is an autoimmune blistering disorder that involves the skin and mucous membranes. Few reports have described nasal and oropharyngolaryngeal lesions in pemphigus vulgaris using an endoscopic ororhinolaryngologic examination. We retrospectively reviewed the clinical records of 11 patients with pemphigus vulgaris between 2001 and 2013 with respect to their symptoms, lesion sites, lesion features, and treatments received. All patients had undergone an endoscopic ororhinolaryngologic examination. Their mucosa-related symptoms were sore throat, oral pain, odynophagia, gingival bleeding, hoarseness, and epistaxis. The most frequent sites were the oral cavity (gingiva and buccal mucosa), larynx (epiglottis and vocal fold), oropharynx (soft palate), and nasal cavity (nasal septum). Lesions were typically characterized by erosion, erosion with a whitish exudate, and erythematous patches. Thus, our study findings reveal that pemphigus vulgaris involves both the nasal and oropharyngolaryngeal regions. Patients with pemphigus vulgaris should undergo an endoscopic ororhinolaryngologic examination to determine the range of their lesions.

Atypical Eosinophilic Esophagitis

The classic endoscopic findings of eosinophillic esophagitis (EoE) are linear furrowing, concentric esophageal rings, diminished vascular pattern, white surface exudates and linear tears. Occasionally, in severe cases of EoE, a small caliber esophagus and strictures can be seen. These findings are not pathognomonic but collectively suggest the diagnosis of EoE. In this case report, we present a rare endoscopic finding of an esophageal polyp secondary to eosinophillic esophagitis. A 36-year-old Italian woman presented with burning chest discomfort, difficulty swallowing and regurgitation of food for the past year. She reports a history an esophageal tumor diagnosed 19 years earlier, treated with multiple sessions of laser ablation therapy. Due to progressively worsening symptoms she underwent an upper endoscopy and was found to have a single, 3cm semi-pedunculated polyp in the distal esophagus. Multiple biopsies were taken and pathology revealed esophageal mucosa with a focal marked increase in intraepitheal eosinophils. The patient was referred for Endoscopic Ultrasound (EUS) with Endoscopic Mucosal Resection (EMR). Upon further questioning she admitted to having a history of asthma and seasonal allergies, raising suspicion for EoE. She was given a trial of prednisone and proton pump inhibitor. Two weeks later EUS evaluation revealed a single, small 5mm polyp in the distal esophagus. Pathology revealed fragments of a squamous papilloma with acute inflammation. The patient was diagnosed with an atypical endoscopic manifestation of eosinophillic esophagitis. Eosinophilic esophagitis is an allergy-associated disease increasingly recognized in industrialized countries. The prevalence is estimated to reach up to 50 patients per 100,000 people in some regions1. It is unclear whether the increase in prevalence is secondary to a rise in incidence or better understanding of the disease. EoE has been described with classic endoscopic findings such as linear furrowing, concentric esophageal rings, diminished vascular pattern, white surface exudates and linear tears. In this case we recognize a unique endoscopic finding of an esophageal polyp in a young woman secondary to EoE. In review of the literature, this rare finding has primarily been described in the pediatric population. This case should heighten awareness of an association between eosinophilic esophagitis and esophageal polyps.

Severe Debilitating Esophageal Dysphagia: A Rare Complication of Cardiac Radiofrequency Ablation

Introduction: Left atrial radiofrequency ablation (LA-RFA) is a successful and relatively safe treatment for atrial fibrillation (AF). Major complications have been reported at a rate of 2-6%, but associated esophageal injury has been rarely reported. Clinical and endoscopic presentation is variable, and prompt management is critical to avoid poor outcomes. We present a unique case of severe esophageal dysphagia caused by LA-RFA. Case Report: A 67-year-old man presented with acute onset of dysphagia to solids 5 days following coronary artery bypass surgery (CABG) and LA-RFA for AF. He had associated chest discomfort, weight loss of 45 pounds in 5 months and impaired quality of life. He had no previous history of dysphagia or other gastrointestinal conditions. Initial barium swallow and upper endoscopy (EGD) showed inflammation and narrowing of the distal esophageal lumen. Pathology was non-diagnostic. Elsewhere, the patient had received empiric therapy with proton pump inhibitor and fluconazole for 3 weeks to treat candida esophagitis without improvement. Re-evaluation with EGD at our hospital showed severe esophageal stenosis measuring 14cm in length (6mm inner diameter), severe mucosal inflammation and white exudate. Pathology showed necroinflammatory material with granulation tissue. Fungal stain and viral testing were negative. Endoscopic dilation or stenting of this stricture were not attempted due to disease extent and risk of complications. Subsequently, he underwent chest imaging and thoracic surgery consultation followed by successful minimally invasive esophagectomy for ischemic necrosis of the esophagus. Discussion: While LA-RFA is generally safe, esophageal complications have extremely high morbidity and mortality depending on the depth of tissue injury. This unique case of a 14cm esophageal stricture was due to thermal injury from LA-RFA, leading to debilitating dysphagia and malnutrition. The esophagus is vulnerable to thermal injury due to its anatomical location. Understanding the variable clinical presentations and endoscopic findings, in addition to the nature of deep tissue injury is crucial in the management of such cases. Serial chest imaging and early referral to cardiothoracic surgery prevent progression into devastating consequences, like atrio-esophageal fistula (up to 93%). This patient's challenging clinical course exemplifies the need for a high index of suspicion and increased awareness of this elusive diagnosis.Figure 1

Herpes Esophagitis in an Immunocompetent Host

Introduction: Esophagitis caused by HSV is well documented in immunocompromised patients. It is one of the AIDS defining illnesses however there are few cases documented in immunocompetent patients. Corticosteroids and chemotherapies are known risk factors for visceral herpes infections. Steroids are able to inhibit activation, proliferation and differentiation of all cells involved in mounting an immune response, such as T cells. Chemotherapy agents have immunosuppressive effects and cause loss of normal esophageal mucosal integrity, enhancing herpes reactivation. Most immunocompetent affected hosts experience odynophagia, fevers, respiratory symptoms, and dysphagia with anorexia. It generally affects the mid to distal part of the esophagus. In a symptomatic immunocompetent host, the symptoms should be self-resolving. In immunocompetent patients, herpes esophagitis may be a primary infection whereas in an immunocompromised patient, it may be a sign of reactivation of a latent infection. On endoscopy, herpes esophagitis presents as friable mucosa, numerous ulcers, and white exudates involving mid to distal esophagus. The diagnosis is based on endoscopic findings and confirmed by histopathological examination of the lesions, where it appears as ground glass nuclei and multinuclear giant cells. Acyclovir has shown improvement of symptoms in patients that are immunocompromised or immunocompetent. Case Report: 36-year-old female presented with complaints of dysphagia for 2 months. She reported gastroenteritis, fever and genital lesions prior. Her past medical history consisted of migraines and oral candidiasis. Methods: Physical was only significant for mild posterior pharyngeal erythema and moist mucous membranes. Labs were significant for negative HIV titers, positive HSV IgM, EBC IgG and CMV IgG. She underwent an EGD that revealed esophagitis typical of HSV in the middle third of the esophagus and multiple biopsies were taken. Results: All biopsies were negative for HSV. She was started on acyclovir, which led to symptom resolution. Discussion: In healthy patients, esophagitis occurs acutely and is self-limiting. The case presented is that of an immunocompetent patient with negative HIV titers and symptomatic dysphagia. Biopsies during EGD were still negative for HSV however the lesions seen on EGD were typical for HSV. Instead of being self-limited as has been described in other cases, her symptoms were relieved only after treatment with acyclovir.Figure 1

Aspergillus nidulans: A Rare Cause of Invasive Pulmonary Aspergillosis Resulting in Diffuse Alveolar Hemorrhage

SESSION TITLE: Student/Resident Case Report Poster - Chest Infections I SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Invasive Pulmonary Aspergillosis (IPA) is an important source of morbidity and mortality in patients who are immunosuppressed. In the majority of cases, A. fumigatus is the causative species. We present a case of non-fumigatus IPA in patient on immunosuppressive therapy for a history of solid organ transplant. CASE PRESENTATION: Our patient is a 25 year old African American female with a history of cirrhosis secondary to autoimmune hepatitis for which she received a liver transplant in 2012 and had been maintained on immunosuppressive therapy with mycophenolate, prednisone, and tacrolimus. She initially presented to an outside hospital with complaints of fever, cough, and dyspnea. Two weeks prior to that she had been diagnosed with acute on chronic rejection, recurrent cirrhosis, and her prednisone dose was increased. She rapidly decompensated and required intubation. She was then transferred to our institution. Upon arrival copious blood was aspirated from the ET tube. Bronchoscopy revealed a white exudate with intermixed hemorrhage. Lavage culture was positive for A. nidulans. Serum (1-3)-Beta-D-Glucan and BAL/Serum aspergillus antigen ratio were markedly elevated. Rheumatologic workup included a skin biopsy of a rash that developed which was consistent with lupus. She was maintained on antibiotics, antifungals, and immunosuppressives and eventually was discharged to rehab. DISCUSSION: IPA mortality is highest amongst those who have had stem cell transplants or liver transplants. A. fumigatus is the most common causative agent and has been documented to occur in up to 90% of isolates. A. nidulans primarily affects patients with G6PD deficiency. In that population, hyphal angioinvasion is not seen. To our knowledge, only 1 other case of diffuse alveolar hemorrhage has been reported as caused by A. nidulans. Many factors contributed to her respiratory failure from DAH including underlying coagulopathy from cirrhosis, a new diagnosis of lupus, and pre-disposition to IPA from immunosuppression. A. nidulans has occurred more frequently in patients on anti-fungal prophylaxis which may suggest the existence of higher levels of resistance. Increased usage of anti-fungals as prophylaxis, as well as, increasing numbers of stem cell and solid organ transplants may lead to an increased number of cases of IPA and a change in the spectrum of pathology and species encountered. CONCLUSIONS: Atypical aspergillus species are uncommon but are a potential source of significant morbidity and mortality. Increased use of prophylactic anti-fungals may lead to increased resistance in the future. Reference #1: Liu, X., et al. (2011). Invasive fungal infections in liver transplantation. Int J Infect Dis 15(5):e298-304. Reference #2: Henriet S. et al. (2012). Aspergillus nidulans and Chronic Granulomatous Disease: A Unique Host-Pathogen Interaction. J Infect Dis. 206(7):1128-1137. Reference #3: Dimopoulos, G., et al. (2012). Invasive aspergillosis in the intensive care unit. Ann N Y Acad Sci 1272:31-39. DISCLOSURE: The following authors have nothing to disclose: Peter Rattner, Anne Sutherland No Product/Research Disclosure Information

Type 3 gastric neuroendocrine tumor with unique endoscopic features

A 69-year-old man underwent esophagogastroduodenoscopy EGD) for gastric cancer screening. EGD showed a reddish, semiedunculated polypoid lesion in the middle third of the stomach Fig. 1A). Magnifying endoscopy with narrow-band imaging (MBI) revealed whitish exudates on the surface (Fig. 1B). Endoscopic ltrasonography (EUS) disclosed hyperechoic lesion in the subucosal layer (Fig. 1C). The patient was negative for anti-parietal ell and anti-intrinsic factor antibodies. Histological examination of he endoscopically resected specimen showed that the tumor was omposed of uniform cells with ovoid nuclei and eosinophilic cytolasm, proliferation of capillary-sized vessels and fibrin exudates ttached to the surface. The tumor had invaded deep submucosal ayer and was positive for chromogranin A (Fig. 2). The mitotic cells

Eosinophilic Esophagitis in Children and Adolescents with Abdominal Pain: Comparison with EoE-Dysphagia and Functional Abdominal Pain

Aim. Compare EoE-AP with EoE-D for clinical, endoscopy (EGD), histology and outcomes and also with FAP-N. Method. Symptoms, physical findings, EGD, histology, symptom scores, and treatments were recorded for the three groups. Cluster analysis was done. Results. Dysphagia and abdominal pain were different in numbers but not statistically significant between EoE-AP and EoE-D. EGD, linear furrows, white exudates were more in the EoE-D and both combined were significant (p < 0.05). EoE-D, peak and mean eosinophils (p 0.06) and eosinophilic micro abscesses (p 0.001) were higher. Follow-Up. Based on single symptom, EoE-AP had 30% (p 0.25) improvement, EoE-D 86% (p < 0.001) and similar with composite score (p 0.57 and <0.001, resp.). Patients who had follow-up, EGD: 42.8% with EoE-AP and 77.8% with EoE-D, showed single symptom improvement and the eosinophil count fell from 38.5/34.6 (peak and mean) to 31.2/30.4 (p 0.70) and from 43.6/40.8 to 25.2/22.8 (p < 0.001), respectively. FAP-N patients had similar symptom improvement like EoE-D. Cluster Analysis. EoE-AP and FAP-N were similar in clinical features and response to treatment, but EoE-D was distinctly different from EoE-AP and FAP-N. Conclusion. Our study demonstrates that EoE-AP and EoE-D have different histology and outcomes. In addition, EoE-AP has clinical features similar to the FAP-N group.

Pathological Alterations in Carcasses and Viscera of Japanese Quail (Coturnix japonica Temminck &amp; Schlegel, 1849) of Commercial Breeding

Identification of macroscopic injures in japanese quail carcasses during the slaughter process is critical to ensure the high quality of the final product, meat, and decrease the risk of zoonotic diseases. Thus, this study aimed to describe the main pathological changes found in japanese quail in conditions for slaughter process. For this, 31 individuals were sampled at two distinct farms situated in the rural zone of Manaus/AM, all of them with one years old, healthy and in slaughter condition. All analyses were performed in the Laboratory of Triatominae, Phlebotominae and Nidicola fauna of the National Institute for Amazonian Research (INPA), Manaus/AM. “Ante mortem” and “post mortem” inspection were performed in all carcass. Externally, there was only one specimen showed cachexy and apathy. On internal examination, there were changes in the lungs of 9,5% of specimens, it was marked by hyperemia and fibrin exudate in the apical lobes surface. Ulcerations in the proventriculus and ventriculu mucosal were reported in the 9,6% of analyzed birds. Moreover, changes in the small intestine and caecum area were reported respectively in the 45,1% (14) and 74,1 (23) of birds. The most common intestinal disorders were gas accumulation associated with distension of the loops, congested mucosal, and hemorrhagic fluid or yellow colored mucus and petechiae in serous. Three individual showed mucus fluid, dark colored, similar to coffe grounds, in the region of the jejunum, ileum and cecum. Cecum's area of these birds presented one or more species of a parasite nematodes, cestoda and protozoa. 87% (27) of analyzed livers showed a pale aspect, crumbly texture and multifocal areas, units or bilobar, yellowish or greenish gray colored, showed a diameter of 0,2-1,6 cm. In 25,92% of these livers were found scar punctate injures, which showed a grayish or blackish color circumscribed by a white halo and petechiae. Ovarian follicles were stunted and two quail oviduct presented fibrinous exudate in serous, while the light of the oviduct found partially obliterated by whitish exudate and caseous mass in the mucosa below the exudate had multiple cysts filled with fluid slightly opaque. Some pathological changes described for C. japonica are simliar to those described for laying hens, however, have also been described macroscopic particular injuries to this species, which suggests further research on this kind of growing economic importance.

Symptoms Have Modest Accuracy in Detecting Endoscopic and Histologic Remission in Adults With Eosinophilic Esophagitis

It is not clear whether symptoms alone can be used to estimate the biologic activity of eosinophilic esophagitis (EoE). We aimed to evaluate whether symptoms can be used to identify patients with endoscopic and histologic features of remission. Between April 2011 and June 2014, we performed a prospective, observational study and recruited 269 consecutive adults with EoE (67% male; median age, 39 years old) in Switzerland and the United States. Patients first completed the validated symptom-based EoE activity index patient-reported outcome instrument and then underwent esophagogastroduodenoscopy with esophageal biopsy collection. Endoscopic and histologic findings were evaluated with a validated grading system and standardized instrument, respectively. Clinical remission was defined as symptom score <20 (range, 0-100); histologic remission was defined as a peak count of <20 eosinophils/mm(2) in a high-power field (corresponds to approximately <5 eosinophils/median high-power field); and endoscopic remission as absence of white exudates, moderate or severe rings, strictures, or combination of furrows and edema. We used receiver operating characteristic analysis to determine the best symptom score cutoff values for detection of remission. Of the study subjects, 111 were in clinical remission (41.3%), 79 were in endoscopic remission (29.7%), and 75 were in histologic remission (27.9%). When the symptom score was used as a continuous variable, patients in endoscopic, histologic, and combined (endoscopic and histologic remission) remission were detected with area under the curve values of 0.67, 0.60, and 0.67, respectively. A symptom score of 20 identified patients in endoscopic remission with 65.1% accuracy and histologic remission with 62.1% accuracy; a symptom score of 15 identified patients with both types of remission with 67.7% accuracy. In patients with EoE, endoscopic or histologic remission can be identified with only modest accuracy based on symptoms alone. At any given time, physicians cannot rely on lack of symptoms to make assumptions about lack of biologic disease activity in adults with EoE. ClinicalTrials.gov, Number: NCT00939263.