Intussuscepted Polypoid Meckel's Diverticulum Presenting With Gastrointestinal Bleeding in a Young Adult

A 22-year-old female patient with a recent hospitalization for gastrointestinal bleeding presented with recurrent hematochezia and a positive shock index. Previous investigations, including endoscopy and wireless small bowel capsule, were non-diagnostic. CT angiography revealed extravasation in the ileum. Initial tests like technetium-99m scintigraphy and ileocolonoscopy were negative. Repeat wireless small bowel capsule identified a partially ulcerated polypoid mass in the distal ileum. At surgical exploration, an intussuscepted Meckel's diverticulum was identified and resected. A histopathologic examination confirmed the diagnosis. Meckel's diverticulum is a rare cause of gastrointestinal bleeding in adults. Preoperative diagnosis can be challenging. Reports of a polypoid morphology are very scarce in indexed literature and mostly derive from investigation with device-assisted enteroscopy. We report this extremely rare finding at capsule endoscopy to raise clinician awareness and to discuss diagnostic difficulties associated with similar cases, such as the negative scintigraphy result and the optimal timing of repeat capsule endoscopy.

The Impact of the Patras Carnival on the Course of the COVID-19 Pandemic and the Outbreak of Influenza A: A Multicenter Cross-Sectional Study

Background: We investigated the impact of the indoor mass gathering of young people during the Patras Carnival in Greece on the course of the COVID-19 pandemic and the influenza A epidemic. Materials and Methods: For influenza A, we tested 331 subjects with high fever (>38 °C), who arrived at five separate private laboratories over a two-week period after the carnival, via rapid test. One hundred and eighty-eight of them were young adults (17−35 years old), all unvaccinated against influenza A but all immunized against SARS-CoV-2, either through vaccination or previous infection. For the SARS-CoV-2 pandemic, we tested 2062 subjects at two time periods, two weeks before and two weeks after the carnival, also via rapid test. Additionally, we examined 42 samples positive for influenza A and 51 samples positive for SARS-CoV-2 for the possibility of co-infection via molecular testing (i.e., RT-PCR). Results: 177/331 (53.5%) subjects tested positive for influenza A, and 109/177 (61.6%) of the positive subjects were young adults, and 93/109 (85.3%) of these subjects were tested in the first week after the carnival. Additionally, 42 samples of those subjects were molecularly tested, and 5 were found negative for influenza A but positive for SARS-CoV-2. Regarding the SARS-CoV-2 pandemic, the increase in the positivity index for young adults between the pre-carnival and post-carnival periods was moderate. Conclusions: Our study indicates that the indoor mass gathering of young people during the carnival contributed to the outbreak of an influenza A epidemic and had a moderate but not statistically significant impact on the course of the SARS-CoV-2 pandemic, corroborating the crucial role of vaccination against the epidemic’s waves. It also showed the need for the use of high-quality rapid tests for their management.

Acute Upper Gastrointestinal Bleeding: Less Severe Bleeding in More Frail and Older Patients, Comparison Between Two Time Periods Fifteen Years Apart

Background

Acute upper gastrointestinal bleeding (AUGIB) remains a common medical emergency with considerable morbidity and mortality. The aim of this study was to describe the patient characteristics, diagnoses and clinical outcomes of patients presenting with AUGIB nowadays and compare these with those of patients 15 years ago.

Methods

This was a single-center survey of adults (> 16 years) presenting with AUGIB to a tertiary hospital. Data from 401 patients presenting with AUGIB in a tertiary hospital between January 1, 2019 and December 31, 2020 were analyzed and compared with data from 434 patients presenting with AUGIB at the same hospital between January 1, 2004 and December 31, 2005.

Results

Nowadays, patients were older, mean age was 69.5 (± 15.4) vs. 66.2 (± 16.0) years, they had more frequently coexisting diseases (83.5% vs. 72.8%), especially cardiovascular diseases (62.3% vs. 52.5%), and more individuals were inpatients at onset of bleeding (8.2% vs. 4.1%). In addition, more patients were under anticoagulants (18.5% vs. 6.2%), but less were under acetylsalicylic acid ± clopidogrel (36.9% vs. 33.9%). Carlson Comorbidity Index was higher nowadays (5.6 ± 6.4 vs. 3.4 ± 2.3). Moreover, a peptic ulcer was less frequently found as the cause of bleeding (38.4% vs. 56.9%), while more often nowadays endoscopy was negative (12.7% vs. 3.5%). In patients with peptic ulcer, active bleeding on endoscopy was less frequent (7.1% vs. 14.2%). Also, bleeding spots requiring hemostasis were less common on endoscopy (39.6% vs. 49.4%) and more patients were without spots of recent bleeding (49.4% vs. 38.9%). Finally, the rate of rebleeding statistically decreased (7.8% vs. 4.2%), while overall mortality remained relatively unchanged (5.0% vs. 6.2%).

Conclusions

AUGIB episodes nowadays are less severe with less peptic ulcer bleeding, but the patients are older and with more comorbidities.

The impact of metabolic health on non-alcoholic fatty liver disease (NAFLD). A single center experience

BACKGROUND

The role of patients' metabolic clinical and biochemical profile in NAFLD has not been extensively explored.

AIMS

The aim of the study was to assess the role of metabolic health in NAFLD patients and to examine liver disease progression in these populations.

METHODS

The medical charts of 569 patients diagnosed with fatty liver were thoroughly reviewed; 344 patients were excluded because of other chronic liver diseases. Metabolically healthy people were defined as those who met none of the following criteria: blood pressure ≥ 130/85 mmHg or under hypertension treatment, fasting glucose ≥ 100 mg/dl or under diabetes treatment, serum triglycerides > 150 mg/dl, high density lipoprotein-cholesterol <40/50 mg/dl for men/women. Study participants were followed-up over a median period of 22 months.

RESULTS

The present observational case-control study included 225 NAFLD patients; 14 (6.2%) were metabolically healthy. Metabolically healthy participants were younger (p = 0.006), had lower age at diagnosis (p = 0.002), lower levels of γ-GT (p = 0.013), fasting glucose (p <0.001) and triglycerides (p <0.001) and higher HDL-cholesterol (p = 0.005) compared to metabolically non-healthy. By the last follow up assessment, 8 metabolically healthy patients had developed dyslipidemia; 1 patient (14.4%) had presented liver disease progression compared to 8 patients (10.5%) from the unhealthy group (p = 0.567). In multivariate analysis, diabetes mellitus (p = 0.017) and hemoglobin levels (p = 0.009) were the sole independent predictors of disease progression. No significant difference was observed in liver disease progression-free survival rates among the two patient groups (p = 0.503).

CONCLUSIONS

Metabolically healthy NAFLD patients presented with a favorable biochemical profile; however, they were diagnosed with NAFLD at a younger age and the liver disease progression risk was similar to that of metabolically unhealthy patients. These findings suggest that metabolically healthy NAFLD may not constitute a benign condition and patients could potentially be at increased risk of metabolic syndrome and liver disease progression.

Combination of Percutaneous Transhepatic Balloon-Assisted Transjugular Intrahepatic Collateral Caval Shunt and Embolization for Successful Hemostasis of Lower Gastrointestinal Bleeding Associated With Extremely Enlarged Anorectal Varicose Veins

Ectopic varices may frequently occur in the rectum in the context of portal hypertension. Although rectal variceal bleeding is not a frequent bleeding situation, it can be life-threatening unless diagnosed and treated immediately. However, there is no specific treatment strategy established so far. We report a case of a man with extrahepatic portal hypertension and severe hematochezia due to rectal variceal bleeding. The patient was diagnosed in the past with portal vein thrombosis, in the context of myelodysplastic syndrome/myeloproliferative neoplasm overlap syndrome, with ectopic varices in the small intestine, colon, rectum and anal canal, peritoneum and perisplenic veins, treated with mesorenal shunt placement and an oral beta-blocker. After the initial stabilization with fluid replacement and red blood cell transfusion, he underwent endoscopic injection sclerotherapy, with no effect on bleeding episodes, while the large size of the varices precluded the option of endoscopic band ligation. Due to the presence of large collateral veins next to the inferior vena cava, the patient underwent combination therapy with Percutaneous Transhepatic Balloon-Assisted Transjugular Intrahepatic Collateral Caval shunt placement, to decompress portal pressure, followed by angiographic embolization of the feeding vessels resulting in successful hemostasis. Hematochezia ceased, hemoglobin was stabilized and the patient was safely discharged from the hospital. Controlling and treating rectal varices can be a challenging task indicating the need of a multidisciplinary approach. In the absence of well-established treatment guidelines for rectal varices, we highly recommend treatment of refractory ectopic variceal bleeding, non-responsive to endoscopic treatments, with portocaval shunt placement in combination with embolization.

Sweet Syndrome Associated With Crohn’s Disease Developed After a Combo Therapy With Infliximab and Azathioprine: A Case Report

Sweet syndrome, also known as Acute Febrile Neutrophilic Dermatosis, is a rare inflammatory condition. The exact pathogenesis of Sweet syndrome is unclear, however, autoimmune and inflammatory conditions including inflammatory bowel disease have been linked as underlying etiologies. Since its description, in 1964, there have been published less than fifty reports of Crohn’s-associated Sweet syndrome.

We report a 43-year-old male patient with a medical history of Crohn’s disease who subsequently developed Sweet syndrome. Two years after the diagnosis of Crohn’s disease the patient was administered a combo therapy with Infliximab and Azathioprine followed by deep remission. A few months later the patient manifested with skin lesions with histopathological findings suggestive of Sweet syndrome.

Sweet syndrome, although rare, may occur as an extra-intestinal manifestation of Crohn’s disease. This report illustrates the need for a thorough investigation of patients with Crohn’s disease presenting with skin lesions. We hope it will add to the current literature and help understand this rare phenomenon in order to achieve a proper diagnosis.

Olmesartan-Induced Enteropathy: A Report of an Unusual Cause of Chronic Diarrhea

Olmesartan, an angiotensin II receptor blocker indicated in the treatment of hypertension, has been associ­ated with a seronegative sprue-like enteropathy that should be considered in the differential diagnosis of patients with unexplained chronic diarrhoea. It typically presents with severe chronic diarrhoea, considerable weight loss, and villous atrophy on biopsy and may be difficult to recognize because of its clinical and histological similarities to other clinical entities. Practically, discontinuation of the drug leads to dramatic recovery of the symptoms. We report a 76-year-old Caucasian female who was admitted to our hospital with complaints of chronic diarrhea and significant weight loss. Medical history was notable for hypertension being treated with olmesartan. Initially, investigation for all potential infectious causes and celiac disease was negative. Both upper and lower endoscopy was performed with duodenal biopsies revealing total villous atrophy and colonic biopsies showing lymphocytic colitis. In the presence of negative serology for celiac disease and after a thorough review of the patient’s medications, olmesartan in­duced-enteropathy was the most possible diagnosis. Olmesartan was discontinued and the symptoms rapidly resolved. A follow-up done a few months later showed no recurrence of the symptoms. In olmesartan-associated enteropathy, discontinuation of olmesartan results in immediate clinical recovery. Although rare, it is considered an emerging and underdiagnosed enteropathy. This case report illustrates the need for a thorough medication history evaluation and regular review during workup. We aim to increase the awareness of olmesartan-induced enteropathy among clinicians and gastroenterologists. We hope it will add to the current literature and help to understand this rare phenomenon in order to avoid unnecessary testing.

Chilaiditi Syndrome With a Large Colonic Loop in a Patient With Autonomic Nervous System Dysfunction

Chilaiditi syndrome is an unusual condition in which radiographic evidence of a large bowel interposition between the liver and the right hemidiaphragm appears in the chest X-ray. The etiology is unknown and the clinical symptoms vary from case to case. The special characteristics of the syndrome can easily lead to a misdiagnosis and a CT scan is needed to avoid surgical interventions for a suspected pneumoperitoneum. We present a 48-year-old female patient with a medical history of autonomic nervous system dysfunction who referred to the Emergency Department (ED) due to abdominal pain. Chest radiography revealed a radiographic sign of pneumoperitoneum but a CT scan of the abdomen showed interposition of the right colon in the right hemithorax between the diaphragm and the liver without any signs of perforation. The patient was treated with bowel decompression and her symptoms resolved gradually. So far, there is no other case of Chilaiditi syndrome in a patient with autonomic nervous system dysfunction in the published literature. To conclude, Chilaiditi's sign is an unusual radiographic sign presenting as a pneumoperitoneum in the chest X-ray. In order to avoid misdiagnosis and unnecessary surgical interventions, a CT scan should be ordered.

Non-Traumatic Intramuscular Hip Hematoma in a Cirrhotic Patient With Hepatocellular Carcinoma and Portal Vein Thrombosis Treated With Sorafenib and Low Molecular Weight Heparin

Hepatocellular carcinoma (HCC) is a common neoplasm amongst cirrhotic patients and portal vein thrombosis (PVT) is an often found complication. Sorafenib and low molecular weight heparin (LMWH) are considered part of the gold-standard treatment of such patients. Spontaneous intramuscular hematomas of the limbs induced by these agents, as an adverse event, are generally rare. We present a 66-year-old male patient with liver cirrhosis, HCC and PVT treated with Sorafenib and LMWH who developed a non-traumatic hip hematoma. Simple elevation of the lower limb and blood-products infusion was successful in leading to resolution of the symptoms. As the popularity of these agents increases, healthcare providers need to be aware of such treatment adverse events.

Severe impairment of regulatory T-cells and Th1-lymphocyte polarization in patients with Gaucher disease

We investigated peripheral blood T-lymphocyte subpopulations and intracellular expression of IFN-γ, IL-4, IL-10, and IL-13, by whole blood flow cytometry, in 22 type I Gaucher disease (GD) patients. Results were compared with those of 19 sex- and age-matched controls. Patients with GD exhibited decreased frequencies and absolute numbers of CD3+/CD4+ helper T lymphocytes (40.8 ± 9.8% vs. 49.4 ± 5.7%, p = 0.002, and 0.77 ± 0.33 vs. 1.04 ± 0.28 × 10(9)/μL, p = 0.011), as well as increased frequencies of CD3+CD8+ suppressor T lymphocytes (23.8 ± 8.0% vs. 18.4 ± 3.8%, p = 0.010), resulting in a significantly decreased CD4/CD8 cell ratio (p < 0.001). Moreover, they had significantly increased percentages of IFNγ-producing both CD4+ and CD8+ T cells (p = 0.0003 and p = 0.023, respectively), implying a TH-1 polarization pattern. Finally, patients with GD had decreased percentages and absolute numbers of CD4+CD25(dim) T lymphocytes (p = 0.033 and p = 0.007, respectively), of CD4+CD25(high) T lymphocytes (p = 0.039 and p = 0.016, respectively), and of CD4+CD25(high)FOXP3+ regulatory T cells (p = 0.036 and p = 0.019, respectively). Our results demonstrate that patients with GD have a significant numerical impairment of T-helper lymphocytes and a constitutive TH1 direction pattern of activation of both CD4+ and CD8+ cells, associated with a significant decrease of T-regs. Ineffective T-cell control may explain the chronic inflammatory reaction and the increased incidence of lymphoid malignancies, which have been repeatedly reported among patients with GD.

Complete nucleotide sequence of a gene prtR of Porphyromonas gingivalis W50 encoding a 132 kDa protein that contains an arginine-specific thiol endopeptidase domain and a haemagglutinin domain

We have purified from Porphyromonas gingivalis W50 a 45 kDa arginine-specific, thiol-activated, EDTA-sensitive endopeptidase, designated prtR. Oligonucleotide probes based on the N-terminal amino acid sequence were used to isolate a genomic fragment containing an open reading frame (3654 bp) with the potential to encode a 132 kDa protein including the prtR N-terminus. Analysis of this prtR gene revealed that the predicted nascent product contains a protease domain followed by a haemagglutinin domain and is post-translationally processed by proteolytic (possibly autolytic) events to produce a 43-54 kDa arginine-specific, thiol protease and a 41-53 kDa haemagglutinin. Comparison of the prtR with the P. gingivalis prtH gene suggests that the prtH gene product also contains protease and haemagglutinin domains but in the reverse order to that in the prtR. An overlapping but shifted reading frame at the 3' end of the prtR encodes the 5' region of the prtH.

Identification and characterization of Serpulina hyodysenteriae by restriction enzyme analysis and Southern blot analysis

Chromosomal DNA restriction enzyme analysis and Southern blot hybridization were used to characterize Serpulina hyodysenteriae strains. When chromosomal DNAs from selected strains (reference serotypes) of S. hyodysenteriae were digested with the restriction endonuclease Sau3A and hybridized with a 1.1-kb S. hyodysenteriae-specific DNA probe, a common 3-kb band was always detected in S. hyodysenteriae strains but was absent from Serpulina innocens strains. When the chromosomal DNA was digested with the restriction endonuclease Asp 700 and hybridized with two S. hyodysenteriae-specific DNA probes (0.75 and 1.1 kb of DNA), distinct hybridization patterns for each S. hyodysenteriae reference strain and the Australian isolate S. hyodysenteriae 5380 were detected. Neither the 1.1-kb nor the 0.75-kb DNA probe hybridized with Asp 700- or Sau3A-digested S. innocens chromosomal DNA. The presence of the 3-kb Sau3A DNA fragment in S. hyodysenteriae reference strains from diverse geographical locations shows that this fragment is conserved among S. hyodysenteriae strains and can be used as a species-specific marker. Restriction endonuclease analysis and Southern blot hybridization with these well-defined DNA probes are reliable and accurate methods for species-specific and strain-specific identification of S. hyodysenteriae.

Characterization of two DNA probes specific for Serpulina hyodysenteriae

Two DNA probes, one 1.1- and one 0.75-kb probe, specific for Serpulina hyodysenteriae were isolated from a genomic library generated from virulent S. hyodysenteriae 5380. These probes are highly specific and react with all S. hyodysenteriae strains tested. Under stringent conditions, the DNA probes did not react with the nonpathogenic species Serpulina innocens or with other species of enteric bacteria, including Escherichia coli. Both probes are able to detect S. hyodysenteriae in colony blot hybridizations, and when applied to fecal specimens, they can detect 10(4) S. hyodysenteriae cells in 0.1 g of seeded fecal matter. Both probes can detect S. hyodysenteriae in fecal specimens from swine with clinical signs of swine dysentery after experimental challenge and from swine from a herd with an acute outbreak of swine dysentery. These probes have application as a diagnostic tool in veterinary microbiology.