Primary hydatid cyst of the spleen: A rare case report and literature review.

Hydatidosis is an endemic disease in certain areas in the world particularly in the Mediterranean, the Middle East, and South America, caused by a cestode known as Echinococcus granulosus. Humans are the accidental intermediate hosts. The liver and the lungs are the most commonly involved organ. If the parasite passes through the pulmonary capillary bed, the hydatid cyst may develop at any site in the body like bone, pancreas, brain, kidney, and orbit. Isolated spleen hydatid cyst is very rare. We hereby report one observation of isolated hydatid cyst of the spleen in a patient living in non-endemic area and without any potential risk.

Comparative expression of trophoblast cell-surface antigen 2 (TROP2) in the different molecular subtypes of invasive breast carcinoma: An immunohistochemical study of 94 therapy-naive primary breast tumors.

BACKGROUND: Sacituzumab govitecan, targeting trophoblast cell-surface antigen 2 (TROP2), is approved for the treatment of triple-negative and hormone receptor-positive/HER2-negative breast cancers. However, detailed studies comparing TROP2 protein expression in the different molecular subtypes of breast cancer are limited, and definitive evidence supporting the use of TROP2 as a biomarker for predicting response to this agent in patients with breast cancer is currently lacking. OBJECTIVE: To compare the expression of TROP2 in the different molecular subtypes of breast cancer. METHODS: Immunohistochemical staining for TROP2 was performed on 94 therapy-naive primary invasive breast carcinomas, including 25 luminal A-like, 25 luminal B-like, 19 HER2-like, and 25 triple-negative tumors. RESULTS: Intermediate to high levels of TROP2 expression were observed in the majority of carcinomas of each molecular subtype, with a wide range of expression in each subtype. Occasional tumors with low or absent TROP2 expression were encountered, including two metaplastic carcinomas which were completely negative for TROP2. CONCLUSIONS: Our observations support the continued investigation of the efficacy of sacituzumab govitecan in all molecular subtypes of breast carcinoma. Furthermore, the observed wide range of expression of TROP2 suggests that TROP2 may have potential utility as a biomarker for predicting responsiveness to sacituzumab govitecan. If this proves to be the case, then immunohistochemical staining for TROP2 would be critical for identifying those patients whose tumors are completely negative for TROP2, since these patients may be least likely or unlikely to respond to this agent, and alternative therapies may be more appropriate in such instances.

Two distinct pathogenic pathways of digital papillary adenocarcinoma - BRAF mutation or low-risk HPV infection.

Digital papillary adenocarcinoma (DPA) is a rare neoplasm that can exhibit local recurrence and distant metastasis. We present a series of eight cases of DPA showing two distinct clinical presentations, morphologies, immunophenotypes, and molecular features. Four cases were characterized by painless, slow-growing nodules located on the digits. The lesions were small, well-defined, and confined in the dermis. Histopathologically, these tumors were composed of glandular structures lined by cuboidal epithelium with luminal papillary infoldings. Only rare mitotic figures and minimal squamoid differentiation were present, and cellular necrosis was absent. All four cases were positive for the BRAF V600E immunohistochemistry but negative for p16, low-risk and high-risk HPV in situ hybridization (ISH). In contrast, the remaining four cases were characterized by painful, rapidly growing masses on the digits. These four lesions were located in the deep dermis and consisted of a solid, tightly packed papillary architecture lined by atypical epithelioid cells with inconspicuous nucleoli. Cellular necrosis, numerous mitotic figures, and prominent squamoid differentiation were seen. All cases were negative for the BRAF V600E IHC. However, they showed strong, patchy to diffuse reactivity for p16 and were positive for low-risk HPV ISH and negative for high-risk HPV ISH. Our findings suggest that the current classification of DPA encompasses tumors that show two discrete pathogenic pathways - BRAF mutation or low-risk HPV infection. DPAs with low-risk HPV infection exhibit aggressive clinical features, high-grade morphology, marked squamoid differentiation, and wild-type BRAF. DPAs with BRAF V600E have less aggressive clinical features, low-grade morphologic findings, mild to absent squamoid differentiation, and negative HPV infection.

Molecular characterization of visible low-grade dysplastic lesions in patients with inflammatory bowel disease.

We studied pathogenic gene mutations and tumor mutation burden (TMB) in visible low-grade dysplastic lesions in patients with inflammatory bowel disease (IBD). The dysplastic lesions with histologically normal mucosa in the background (group 1) were compared with dysplastic lesions occurring either in a background of chronic active colitis (group 2) or associated with synchronous carcinomas regardless of the status of the background mucosa (group 3). The TMB in group 3 was consistently higher in comparison to the group 1 and group 2 lesions, although the difference was not statistically significant. There also seem to be different mutation profiles between the groups, indicating different pathways of tumor pathogenesis. More frequent APC mutations were seen in group 1 as compared to other groups and TP53 mutations were seen in groups 2 and 3, but none in group 1. Molecular characterization could potentially be used as an ancillary prognostic marker in challenging cases to guide the further management of IBD patients with visible dysplastic lesions.

A Review of COVID-19 in Relation to Metabolic Syndrome: Obesity, Hypertension, Diabetes, and Dyslipidemia.

Although severe cases and mortality of coronavirus disease 2019 (COVID-19) are proportionally infrequent, these cases are strongly linked to patients with conditions of metabolic syndrome (obesity, hypertension, diabetes, and dyslipidemia). However, the pathophysiology of COVID-19 in relation to metabolic syndrome is not well understood. Thus, the goal of this secondary literature review was to examine the relationship between severe acute respiratory syndrome (SARS-CoV-2) infection and the individual conditions of metabolic syndrome. The objective of this secondary literature review was achieved by examining primary studies, case studies, and other secondary studies, to obtain a comprehensive perspective of theories and observations of COVID-19 etiology with metabolic syndrome. The most extensive research was available on the topics of diabetes, hypertension, and obesity, which yielded multiple (and sometimes conflicting) hypothetical pathophysiology. The sources on dyslipidemia and COVID-19 were scarcer and failed to provide an equally comprehensive image, highlighting the need for further research. It was concluded that hypertension had the strongest correlation with COVID-19 incidence (followed by obesity), yet the causative pathophysiology was ambiguous; most likely related to cardiovascular, angiotensin-converting enzyme 2 (ACE-2)-related complications from renin-angiotensin-aldosterone system (RAAS) imbalance. Obesity was also positively correlated to the severity of COVID-19 cases and was believed to contribute to mechanical difficulties with respiration, in addition to hypothetical connections with the expression of ACE-2 on abundant adipose tissue. Diabetes was believed to contribute to COVID-19 severity by producing a chronic inflammatory state and interfering with neutrophil and T-cell function. Furthermore, there were indications that COVID-19 may induce acute-onset diabetes and diabetic ketoacidosis. Lastly, dyslipidemia was concluded to potentially facilitate SARS-CoV-2 infection by enhancing lipid rafts and immunosuppressive functions. There were also indications that cholesterol levels may have prognostic indications and that statins may have therapeutic benefits.

US Severe Acute Respiratory Syndrome Coronavirus 2 Epsilon Variant: Highly Transmissible but With an Adjusted Muted Host T-Cell Response.

BACKGROUND: The multiple mutations comprising the epsilon variant demonstrate the independent convergent evolution of severe acute respiratory syndrome coronavirus (SARS-CoV-2), with its spike protein mutation L452R present in the delta (L452R), kappa (L452R), and lambda (L452Q) variants. METHODS: Coronavirus disease 2019 (COVID-19) variants were detected in 1017 patients using whole-genome sequencing and were assessed for outcome and severity. The mechanistic effects of the epsilon versus non-epsilon variants were investigated using a multiomic approach including cellular response assays and paired cell and host transcriptomic and proteomic profiling. RESULTS: We found that patients carrying the epsilon variant had increased mortality risk but not increased hospitalizations (P < .02). Cells infected with live epsilon compared with non-epsilon virus displayed increased sensitivity to neutralization antibodies in all patients but a slightly protective response in vaccinated individuals (P < .001). That the epsilon SARS-CoV-2 variant is more infectious but less virulent is supported mechanistically in the down-regulation of viral processing pathways seen by multiomic analyses. Importantly, this paired transcriptomics and proteomic profiling of host cellular response to live virus revealed an altered leukocyte response and metabolic messenger RNA processing with the epsilon variant. To ascertain host response to SARS-CoV-2 infection, primary COVID-19-positive nasopharyngeal samples were transcriptomically profiled and revealed a differential innate immune response (P < .001) and an adjusted T-cell response in patients carrying the epsilon variant (P < .002). In fact, patients infected with SARS-CoV-2 and those vaccinated with the BNT162b2 vaccine have comparable CD4+/CD8+ T-cell immune responses to the epsilon variant (P < .05). CONCLUSIONS: While the epsilon variant is more infectious, by altering viral processing, we showed that patients with COVID-19 have adapted their innate immune response to this fitter variant. A protective T-cell response molecular signature is generated by this more transmissible variant in both vaccinated and unvaccinated patients.

The role of double-guidewire technique in preventing postendoscopic retrograde cholangiopancreatography pancreatitis.

BACKGROUND AND STUDY AIMS: Postendoscopic retrograde cholangiopancreatography (ERCP) complications increase with repeated cannulation attempts. We evaluated several advanced biliary cannulation techniques, which have been used when the standard approach fails, to increase the success rate and decrease post-ERCP complications. We aimed to evaluate the use of double-wire technique in terms of success rates and effects on post-ERCP pancreatitis (PEP) and to assess the value of pancreatic duct stenting following needle-knife sphincterotomy in difficult biliary cannulation. PATIENTS AND METHODS: A single-center, retrospective, randomized study was conducted on patients who underwent ERCP in Notre Dame De Secours University Hospital at Byblos, Lebanon, after obtaining the hospital's ethics committee approval. Patients were divided into three groups. The first group consisted of patients who had an ERCP and was divided into two subgroups, namely, one usingdouble-guidewire technique (DGT) only and another using an extra technique of precut with double-guidewire and pancreatic plastic stent placement. The second group of patients who had only ERCP was the control group. Finally, the third group endured the precut technique alone. RESULTS: We could not prove any significant association between the intervention and the occurrence of pancreatitis when comparing double-wire technique plus ERCP to ERCP alone. When DGT with a pancreatic plastic stent was used, the incidence of PEP was significantly lower than that in other techniques. CONCLUSION: DGT has a neutral effect on the reduction of PEP compared with the classic ERCP, but the technique can decrease the time of examination and increase success in difficult cases. ERCP using the double-guidewire with placement of a pancreatic plastic stent can contribute to decreasing PEP.

Improvement in plasma D-dimer level in severe SARS-CoV-2 infection can be an indicator of fibrinolysis suppression: Case reports.

RATIONALE: Fibrinolysis shutdown associated with severe thrombotic complications is a recently recognized syndrome that was previously seldom investigated in patients with severe severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. It presents a unique therapeutic dilemma, as anticoagulation with heparin alone is insufficient to address the imbalance in fibrinolysis. And while the use of fibrinolytic agents could limit the disease severity, it is often associated with bleeding complications. There is a need for biomarkers that will guide the timely stratification of patients into those who may benefit from both anticoagulant and fibrinolytic therapies. PATIENT CONCERNS: All 3 patients presented with shortness of breath along with comorbidities predisposing them to severe SARS-CoV-2 infection. One patient (Patient 3) also suffered from bilateral deep venous thrombosis. DIAGNOSES: All 3 patients tested positive for SARS-CoV-2 RNA by reverse transcription polymerase chain reaction (RT-PCR) and were eventually diagnosed with respiratory failure necessitating intubation. INTERVENTIONS: All 3 patients required mechanical ventilation support, 2 of which also required renal replacement therapy. All 3 patients were also placed on anticoagulation therapy. OUTCOMES: In Patients 1 and 2, the initial D-dimer levels of 0.97 µg/ml fibrinogen equivalent units (FEU) and 0.83 µg/ml FEU were only slightly elevated (normal <0.50 µg/ml FEU). They developed rising D-dimer levels to a peak of 13.21 µg/ml FEU and >20.0 µg/ml FEU, respectively, which dropped to 1.34 µg/ml FEU 8 days later in Patient 1 and to 2.94 µg/ml on hospital day 13 in Patient 2. In Patient 3, the D-dimer level on admission was found to be elevated to >20.00 µg/ml FEU together with imaging evidence of thrombosis. And although he received therapeutic heparin infusion, he still developed pulmonary embolism (PE) and his D-dimer level declined to 5.91 µg/ml FEU. Despite "improvement" in their D-dimer levels, all 3 patients succumbed to multi-system organ failure. On postmortem examination, numerous arterial and venous thromboses of varying ages, many consisting primarily of fibrin, were identified in the lungs of all patients. LESSONS: High D-dimer levels, with subsequent downtrend correlating with clinical deterioration, seems to be an indicator of fibrinolysis suppression. These findings can help form a hypothesis, as larger cohorts are necessary to demonstrate their reproducibility.

Targeted next-generation sequencing supports serrated epithelial change as an early precursor to inflammatory bowel disease-associated colorectal neoplasia.

Serrated epithelial change (SEC) manifests in patients with long-standing inflammatory bowel disease (IBD) and is characterized by disorganized crypt architecture, irregular serrations, and goblet cell-rich epithelium. The serrated nature of SEC is reminiscent of serrated colorectal polyps, which frequently harbor KRAS/BRAF mutations. SEC is, however, not only histologically distinct from sporadic serrated polyps but also associated with colorectal neoplasia. Whether SEC is a precursor to IBD-associated neoplasia remains unclear. To further define the relationship of SEC with serrated colorectal polyps and IBD-associated neoplasia, we performed targeted next-generation sequencing on colorectal specimens to include the following: SEC without dysplasia/neoplasia (n = 10), SEC with separate foci of associated dysplasia/adenocarcinoma from the same patients (n = 17), and uninvolved mucosa (n = 10) from 14 patients. In addition, we molecularly profiled sessile serrated lesion (SSL)-like or serrated lesion, not otherwise specified (SL-NOS), specimens, from 11 patients who also had IBD. This control cohort included SSL-like/SL-NOS without dysplasia/neoplasia (n = 11), SSL-like/SL-NOS with associated low-grade dysplasia (n = 2), and uninvolved mucosa (n = 8). By next-generation sequencing, the most frequently mutated gene in SEC without neoplasia and associated dysplasia/adenocarcinoma from separate foci in the same patients was TP53. Recurrent TP53 mutations were present in 50% of SEC specimens without dysplasia/neoplasia. In addition, alterations in TP53 were detected at a prevalence of 71% in low-grade dysplasia, 83% in high-grade dysplasia, and 100% in adenocarcinoma. Paired sequencing of SEC and associated neoplasia revealed identical TP53 missense mutations for 3 patients. In contrast, 91% of SSL-like/SL-NOS specimens without dysplasia/neoplasia harbored KRAS/BRAF mutations, which were conserved in associated low-grade dysplasia. No genomic alterations were found in uninvolved mucosa from either patients with SEC or patients with SSL-like/SL-NOS. Based on our findings, we conclude SEC is distinct from SSL-like serrated colorectal lesions in patients with IBD and an early precursor to IBD-associated neoplasia that warrants colonoscopic surveillance.

Cell polarity (the 'four lines') distinguishes gastric dysplasia from epithelial changes in reactive gastropathy.

AIMS: Gastric dysplasia is a risk factor for synchronous and subsequent gastric carcinoma. Distinguishing gastric dysplasia from reactive changes is subject to interobserver disagreement and is a frequent reason for expert consultation. We previously used assessment of surface cell polarity (the 'four lines') as a key feature to decrease equivocal diagnoses in Barrett oesophagus. In the current study, we examined for the presence or absence of the four lines in gastric dysplasia and reactive gastropathy. MATERIALS AND METHODS: The study includes all (n = 91) in-house biopsies with at least gastric dysplasia from the surgical pathology archives of two academic institutions during a 5-year period from 2008 to 2012. A reactive gastropathy group (n = 60) was created for comparison. RESULTS: The dysplasia/neoplasia group was comprised of 14 biopsies of gastric foveolar-type dysplasia, 59 of intestinal-type dysplasia, 14 with dysplasia in fundic gland polyps, three pyloric gland adenomas and one oxyntic gland adenoma. Loss of surface cell polarity was seen in all 88 dysplasia cases with evaluable surface epithelium. All 57 reactive gastropathy cases with evaluable surface epithelium showed intact surface cell polarity except in focal areas directly adjacent to erosions in 17 cases, where the thin wisp of residual surface mucin could not be appreciated on haematoxylin and eosin. CONCLUSION: Surface cell polarity (the four lines) was lost in all gastric dysplasia biopsies with evaluable surface epithelium and maintained in all biopsies of reactive gastropathy. Caution should be taken in using this feature adjacent to erosions in reactive gastropathy.

Personal Protective Equipment for Endoscopy in Low-Resource Settings During the COVID-19 Pandemic: Guidance From the World Gastroenterology Organisation.

Performance of endoscopic procedures is associated with a risk of infection from COVID-19. This risk can be reduced by the use of personal protective equipment (PPE). However, shortage of PPE has emerged as an important issue in managing the pandemic in both traditionally high and low-resource areas. A group of clinicians and researchers from thirteen countries representing low, middle, and high-income areas has developed recommendations for optimal utilization of PPE before, during, and after gastrointestinal endoscopy with particular reference to low-resource situations. We determined that there is limited flexibility with regard to the utilization of PPE between ideal and low-resource settings. Some compromises are possible, especially with regard to PPE use, during endoscopic procedures. We have, therefore, also stressed the need to prevent transmission of COVID-19 by measures other than PPE and to conserve PPE by reduction of patient volume, limiting procedures to urgent or emergent, and reducing the number of staff and trainees involved in procedures. This guidance aims to optimize utilization of PPE and protection of health care providers.

Case report about the management of a late Gastro-Gastric Fistula after Laparoscopic Gastric Bypass, with the finding of an unexpected foreign body.

BACKGROUND: Gastro-Gastric Fistula is a rare but potentially serious complication of Roux-en-Y Gastric Bypass. Orogastric tube stapling is an adverse bariatric surgery iatrogenic complication that surgeons should be aware of and that has rarely been described. CLINICAL CASE: A 51-year-old patient, operated in our University Hospital Center of a Gastric Bypass 3 years ago, presented on consultation with anemia and weight regain (BMI 36). An upper Gastrointestinal (GI) endoscopy showed a Gastro-Gastric Fistula and visualized the tip of a Faucher tube fixed in the blind pouch and an erosive ulceration on the gastrojejunal anastomosis. Multiple biopsies showed a low-grade dysplasia in the remnant stomach. A subtotal gastrectomy was performed with refashioning of the gastrojejunal anastomosis. DISCUSSION: Anemia and weight regain, with or without the association of marginal ulcers are the most common signs of Gastro-Gastric Fistula after Gastric Bypass (1-6%). Surgical treatment remains the standard of care and should be tailored to the size and location of the fistula and the status of the gastrojejunal anastomosis. Orogastric tube perioperative complications are rare occurrences during bariatric surgery and not reported at a later stage. They can be associated with significant morbidity. Prevention strategies must be taken and standardized to prevent such events. CONCLUSION: The surgical option remains the standard of treatment and can be performed safely in Gastro-Gastric Fistula Type II. Orogastric tube accidental complications should be identified preferably perioperatively and measures of prevention should be implied to avoid such events.

Large paraesophageal hernia in elderly patients: Two case reports of laparoscopic posterior cruroplasty and anterior gastropexy.

BACKGROUND: Paraesophageal hernia (PEH) is a rare form of hiatal hernia, which commonly occurs in elderly people. Although asymptomatic, it can be associated with severe life-threatening complications, such as gastric volvulus. Surgical treatment is reserved for symptomatic patients. Herein, we present two cases of complicated PEH that were treated with laparoscopic posterior cruroplasty and anterior gastropexy. CASE SUMMARY: An 88-year old woman presented with epigastric pain, hematemesis and food intolerance for the last two days. Physical exam revealed mild abdominal distention. Chest X-ray showed a left thoracic opacity, and barium swallow images showed a mixed type III PEH. Abdominal CT-scan images confirmed the diagnosis of incomplete gastric volvulus. The patient underwent a laparoscopic hernia reduction with sac excision, posterior cruroplasty and anterior gastropexy with continuous barbed suturing. The postoperative course was uneventful, and follow-up showed complete resolution of her symptoms. A 91-year old patient was admitted for dyspnea and fever, with vomiting and food intolerance for the last 7 days. Physical exam revealed absent sounds on both lungs. Chest X-ray showed a large left opacity. CT-scan images revealed a giant PEH with complete gastric volvulus. The patient underwent emergency laparoscopic hernia reduction and sac excision, with re-inforced posterior cruroplasty, and anterior gastropexy with continuous barbed suturing. There were no surgical complications, but the patient died on the 4th day postoperatively due to respiratory failure. CONCLUSION: Early laparoscopic posterior cruroplasty and anterior gastropexy is a safe and effective surgical alternative for elderly patients with comorbidities, presenting with symptomatic PEH.

Does rectal ketoprofen prevent post ERCP pancreatitis?

BACKGROUND AND STUDY AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly used procedure in the management of pancreatic and biliary diseases. Acute pancreatitis is the most common complication following ERCP. Among many medications, nonsteroidal anti-inflammatory drugs (NSAIDs) were subject of numerous trials concerning post ERCP pancreatitis (PEP) prophylaxis. By inhibiting phospholipase A2, these drugs could intervene in the pathogenesis of the disease therefore limiting its occurrence. The use of some rectal NSAIDs agents was shown, to be advantageous in preventing this complication but there were not enough data on ketoprofen. The aim of this study was to assess the efficacy of rectal ketoprofen prophylactic administration in reducing the risk of PEP. PATIENTS AND METHODS: The study was a non randomized retrospective single center study conducted between 2014 and 2018 on 242 patients divided into control and trial group receiving 100 mg of rectal Ketoprofen 30 mins before ERCP. PEP was defined as a new or exacerbated abdominal pain, in association with an elevation of serum lipase at least three times higher than the normal upper limit within and lasting more than 24 h after the procedure requiring a re-admission or a prolongation of the hospital stay. This endpoint was determined by comparing the number of patients presenting PEP in the NSAIDs group vs. the control group using Fisher exact test, with p < 0.05 representing a significant statistical value. RESULTS: Pancreatitis developed in 6% after ERCP, 5 of them being in the trial group and 9 in the control group. Additionally, statistical calculations showed a non significant difference between the two groups in the prevalence of PEP. CONCLUSION: Rectal ketoprofen administration before ERCP does not have any effect in preventing pancreatitis post ERCP.

Schwannoma of the psoas: An unusual cause of abdominal pain.

Schwannomas are usually benign tumours arising from Schwann cells of peripheral nerve sheath. Retroperitoneal location is extremely rare compromising 0.5-5% of all schwannomas, except in patients having von Recklinghausen's disease, in whom retroperitoneal location is more frequent and malignant cases are known to occur. Complete surgical excision with negative margins is the definitive treatment on which the diagnosis is usually made due to nonspecific radiologic appearance. In this article we would like to present an unusual cause of recurrent, abdominal pain in an eighty-six-year-old male.

Pancreatic panniculitis: a rare complication of pancreatitis secondary to ERCP.

Panniculitis is an uncommon and rare complication of systemic fat necrosis in patients with pancreatic diseases. The skin manifestations are independent of the severity of the pancreatic pathology and can occur at any time. The lesions can precede, be concomitant with or rarely follow the pancreatic illness. We report a case of acute pancreatitis post Endoscopic Retrograde Cholangio Pancreatography (ERCP) for common bile duct stone, with subcutaneous panniculitis. We noted a complete resolution within two weeks after the treatment of the pancreatic pathology.