The Great Mimicker Gets Caught: A Rare Case of Syphilis in the Gastrointestinal Tract.

Syphilis is a sexually transmitted disease that impacts multiple organ systems and can mimic various diseases and is an extremely rare cause of proctitis in men who have sex with men and transgender females. We present a case of a 49-year-old transgender female with a medical history significant for diabetes mellitus and hyperlipidemia who presented to the emergency department with dull abdominal pain in the left upper and lower quadrants for two days. She had non-bloody, nonbilious emesis, 10-pound weight loss over 1 month, and constipation for 2 weeks. Laboratory results showed a cholestatic pattern. Computed tomography of the abdomen showed rectal wall thickening, multiple enlarged perirectal adenopathy, and mild inflammatory infiltration around the rectum suggesting superimposed proctitis. On colonoscopy, a possible rectal mass or severe proctitis with near complete obstruction was seen with initial pathology concerning for lymphoma or a rare type of colitis. The patient was empirically started on ceftriaxone and doxycycline leading to improvement in inflammation. Special stains requested were positive for Treponema pallidum confirming the diagnosis of syphilitic proctitis and highly suggestive syphilitic hepatitis. Few cases of syphilitic proctitis imitating rectal malignancy and syphilitic hepatitis have been reported. Syphilis requires exclusion as well as confirmation of spirochetes for high-risk populations with special staining. It is important to diagnose syphilis in special populations that are at high risk of contraction.

A Complex Presentation of Esophageal Pseudodiverticulosis With Candida Albicans Esophagitis in a 68-Year-Old Female.

Esophageal pseudodiverticulosis, a rare condition, involves small sac-like structures in the esophageal wall, stemming from dilated excretory ducts of submucosal glands. While uncommon, it can complicate Candida albicans esophagitis, a yeast infection linked to various clinical issues, including pseudodiverticula formation. This unique association underscores the importance of understanding its clinical implications and optimal management. In this case, a 68-year-old female sought medical attention for dysphagia and recurrent food impaction. The diagnostic journey revealed esophageal pseudodiverticulosis and Candida albicans esophagitis, emphasizing the complexity of esophageal disorders.

Submucosal Lipoma in the Rectum Found Incidentally During Colonoscopy Screening: A Case Report.

Gastrointestinal (GI) tract lipomas are a benign entity of GI tumors. In this case report, we present a 53-year-old patient who was found to have a rectal lipoma incidentally in an asymptomatic middle-aged female during a routine colonoscopy screening. The tumor was excised during colonoscopy and sent for histopathology, which confirmed the diagnosis. We also provide a literature review of GI lipomas, focusing on their occurrence in the rectum.

Symptomatic Gastric Diverticulum in the Antrum: A Case Report.

Gastric diverticulum is an out-pouching that occurs in the gastric wall and, often, when found, is incidental and asymptomatic. While they do not occur commonly, gastric diverticula are located most commonly in the posterior wall of the fundus of the stomach, and their presence in the antrum, as appreciated in the case described below, is quite rare. We present a 65-year-old female who was found to have an antral gastric diverticulum on esophagogastroduodenoscopy (EGD). There have been a few reported cases in the literature of gastric diverticulum that occurred in the antrum. This case report will shed light on this rare pathology, focusing on the occurrence in the antrum.

A Rare Presentation of Synchronous Colorectal Adenocarcinoma.

Synchronous carcinoma is defined as multiple malignant lesions presented in a single patient at initial diagnosis. Synchronous colorectal adenocarcinoma is a rare entity that has been increasingly recognized, likely due to the significant improvement in imaging and diagnostic tools. Making the appropriate diagnosis of synchronous colorectal cancer has a major role in the management's determination and treatment plans. Herein, we are reporting a case of a 73-year-old gentleman who was diagnosed with synchronous colorectal adenocarcinoma with two masses in the left colon and was treated initially surgically followed by chemotherapy.

Beyond the Expectation: Pembrolizumab-Associated Tumor Lysis Syndrome in Metastatic Gastric Adenocarcinoma.

Tumor lysis syndrome (TLS) emerges as a critical oncological emergency, a consequence of the body's struggle to manage the intense cellular turnover and release of cytotoxins induced by treatments such as chemotherapy, radiation, targeted immune therapy, or hormonal therapy. While commonly associated with hematological malignancies, the heightened risk also extends to advanced-stage solid tumors and instances of liver metastasis. Although TLS is a rare occurrence in gastric adenocarcinoma, reported cases are usually linked to the initiation of chemotherapy. Remarkably, the incidence of TLS following the commencement of pembrolizumab in gastric adenocarcinoma remains undocumented in the existing literature. In this context, we present a compelling case involving a 73-year-old gentleman diagnosed with advanced-stage metastatic gastric adenocarcinoma. Strikingly, the patient developed TLS subsequent to the initiation of pembrolizumab (Keytruda®). This unique scenario not only accentuates the atypical manifestation of TLS in the context of gastric adenocarcinoma but also underscores the need for heightened awareness and exploration of potential complications associated with immunotherapeutic agents in solid tumor settings. The detailed analysis of this case contributes valuable insights that may prove instrumental in refining our understanding of the intricate interplay between immunotherapy and tumor lysis syndrome in the specific landscape of gastric adenocarcinoma.

Transient Ischemic Attack, the Initial Presentation of Azygos to Pulmonary Vein Fistula.

There are different sources of cerebral emboli, including cardiac embolism, extracranial arterial embolism, paradoxical embolism, trauma, and iatrogenic embolism. In rare cases, atypical sources should be ruled out. We are reporting a lady who presented with transient ischemic attack and had a fistula between the azygos to the pulmonary vein. (Level of Difficulty: Advanced.).

Association of Non-Alcoholic Fatty Liver Disease and Metabolic-Associated Fatty Liver Disease with COVID-19-Related Intensive Care Unit Outcomes: A Systematic Review and Meta-Analysis.

Background and Objective: The association of non-alcoholic fatty liver disease (NAFLD) and metabolic-associated fatty liver disease (MAFLD) with intensive care unit (ICU) admissions and the need for mechanical ventilation and disease severity in COVID-19 patients. Material and Methods: A systematic literature review was conducted on the databases: Cochrane, Embase, PubMed, ScienceDirect, and the Web of Science from January 2019 to June 2022. Studies evaluating MAFLD using laboratory methods, non-invasive imaging, or liver biopsy were included. The study protocol was registered in PROSPERO (ID CRD42022313259), and PRISMA guidelines were followed. The NIH quality assessment tool was used for quality assessment. RevMan version 5.3 software was used for pooled analysis. A sensitivity analysis was performed to assess the result's stability. Results: A total of 37,974 patients from 17 studies were assessed for the association between MAFLD and ICU admission. A total of 3396 COVID-19 patients required ICU admission: 1236 (20.41%) in the MAFLD group and 2160 (6.77%) in the non-MAFLD group. The odds ratio was 1.86 for ICU admission, p = 0.007, and a (95% CI) of [1.18-2.91]. A total of 37,166 patients from 13 studies were included in the need for invasive mechanical ventilation analysis. A total of 1676 patients required mechanical ventilation: 805 in the MAFLD group (14.20% of all MAFLD patients) and 871 patients in the non-MAFLD group (2.76% of all non-MAFLD patients). The odds ratio was 2.05, p = 0.02, and a (95% CI) of [1.12-3.74]. A total of 5286 patients from 14 studies were included in the COVID-19 disease severity analysis. Severe COVID-19 was seen in 1623 patients, with 33.17% (901/2716) of MAFLD patients and 28.09% (722/2570) of non-MAFLD patients having severe disease. The odds ratio was 1.59 for disease severity, p = 0.010, and a (95% CI) of [1.12-2.26]. Conclusions: Our meta-analysis suggests that there are significantly increased odds of ICU admissions, a need for invasive mechanical ventilation, and disease severity in MAFLD patients who acquire COVID-19.

Association of non-alcoholic fatty liver and metabolic-associated fatty liver with COVID-19 outcomes: A systematic review and meta-analysis.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) and metabolic-associated fatty liver disease (MAFLD) are on the rise like any other liver disease, and tend to affect 25% of the United States population. The impact of NAFLD and MAFLD on patients with coronavirus disease 2019 (COVID-19) remains unclear. AIM: To identify the association of NAFLD and MAFLD with mortality, hospitalization, hospital length of stay, and supplemental oxygen utilization in COVID-19 patients. METHODS: A systematic review of literature on Cochrane, Embase, PubMed, ScienceDirect, and Web of Science databases was conducted from January 2019 to July 2022. Studies that evaluated NAFLD/MAFLD using laboratory methods, noninvasive imaging, or liver biopsy were included. The study protocol was registered in PROSPERO (ID CRD42022313259) and PRISMA guidelines were followed. The National Institutes of Health quality assessment tool was used to assess the quality of the studies. Pooled analysis was conducted using software Rev Man version 5.3. The stability of the results was assessed using sensitivity analysis. RESULTS: Thirty-two studies with 43388 patients were included in the meta-analysis of whom 8538 (20%) patients were observed to have NAFLD. There were 42254 patients from 28 studies included in the mortality analysis. A total of 2008 patients died from COVID-19; 837 (10.52%) in the NAFLD group and 1171 (3.41%) in the non-NAFLD group. The odds ratio (OR) was 1.38 for mortality with a 95% confidence interval (95%CI) = 0.97-1.95 and P = 0.07. A total of 5043 patients from eight studies were included in the hospital length of stay analysis. There were 1318 patients in the NAFLD group and 3725 patients in the non-NAFLD group. A qualitative synthesis showed that the mean difference in hospital length of stay was about 2 d between the NAFLD and non-NAFLD groups with a 95%CI = 0.71-3.27 and P = 0.002. For hospitalization rates, the OR was 3.25 with a 95%CI of 1.73-6.10 and P = 0.0002. For supplemental oxygen utilization, the OR was 2.04 with a 95%CI of 1.17-3.53 and P = 0.01. CONCLUSION: Our meta-analysis suggests that there are increased odds of hospitalization, longer hospital length of stay, and increased use of supplemental oxygen in NAFLD/MAFLD patients.

Urinothorax, a rare complication of rupture renal calyx.

Urinothorax is one of the rare causes of pleural effusion of extra-vascular origin, commonly presents with a transudative pleural effusion due to obstruction, injury or trauma to the genitourinary tract. It is not a common cause which increases the likelihood of underdiagnosis or misdiagnosis. Herein, we are presenting a 65-year-old gentleman who presented with urinary symptoms found to have urinothorax secondary to urinary tract obstruction by benign prostatic hypertrophy. This case was further complicated by urinoma and pyelonephritis. We are reporting this case to highlight the importance of including this entity in the differential diagnosis in patients who have pleural effusion especially if they presented with obstructive urinary symptoms.

Lemmel's Syndrome: A Rare Complication of Periampullary Diverticula.

Periampullary diverticula are outpouches in the mucosa in the duodenum surrounding the ampulla of Vater. Most cases of periampullary diverticuli are asymptomatic, but complications can arise, increasing a patient's mortality. Diagnosis of periampullary diverticuli is often incidental during endoscopy or imaging studies for abdominal pain. When a patient with periampullary diverticuli is symptomatic, imaging modalities such as CT scan and MRI can help make the diagnosis, but a side-viewing endoscope provides direct visualization of the diverticuli and also allows for the potential treatment of the disease. Lemmel's syndrome is a complication of periampullary diverticuli where the diverticuli causes mechanical obstruction of the bile duct leading to obstructive jaundice without choledocholithiasis. These patients are at risk for further complications such as sepsis and perforation. Early diagnosis and treatment of these patients can help to prevent further complications from arising. We are presenting a case of Lemmel's syndrome with obstructive jaundice from a periampullary diverticuli, further complicated by cholangitis without dilation of the biliary tree.

Post-paracentesis scrotal edema: A case report.

Abdominal paracentesis is a common and safe procedure used to remove ascitic fluid from the body. It is performed in both the inpatient and outpatient setting and can be used for both diagnostic and therapeutic purposes. The most common complications of this procedure include a persistent fluid leak, an infection from the puncture site and an abdominal wall hematoma. The finding of sudden-onset massive genital swelling is a rare, and only occasionally reported, complication of a paracentesis. This article will discuss the case of a 58-year-old male with decompensated liver cirrhosis who presented with sudden-onset scrotal and penile swelling within 12 h after a paracentesis. After ruling out other causes of scrotal swelling, it was concluded that this is likely a complication of the recent paracentesis. The scrotal swelling was treated with conservative management including oral diuretic therapy and scrotal elevation, and the patient showed significant improvement in symptoms in 2 days. The cause of post-paracentesis scrotal edema is not widely studied; however, it is hypothesized to be caused by a fistula tract that forms between the peritoneal cavity and the Camper's and Scarpa's fascia which causes fluid to collect in the scrotum.

Concise review on short bowel syndrome: Etiology, pathophysiology, and management.

Adults have approximately 20 feet of small intestine, which is the primary site for absorbing essential nutrients and water. Resection of the intestine for any medical reason may result in short bowel syndrome (SBS), leading to loss of major absorptive surface area and resulting in various malabsorption and motility disorders. The mainstay of treatment is personalized close dietary management. Here we present SBS with its pathophysiology and different nutritional management options available. The central perspective of this paper is to provide a concise review of SBS and the treatment options available, along with how proper nutrition can solve major dietary issues in SBS and help patients recover faster.

A rare case of diffuse large B-cell lymphoma presenting as a malignant mass in both duodenum and ascending colon.

Lymphoma in the gastrointestinal tract most commonly occurs in the stomach, small intestine and around the ileocecal region. Usually gastrointestinal lymphoma occurs secondary to widespread nodal disease and is rarely found to be the primary site. Of the different types of lymphoma, diffuse large B-cell non-Hodgkin's lymphoma makes up the majority of lymphomas in the gastrointestinal tract. Primary colorectal lymphoma is even less common and accounts for 3% of all gastrointestinal lymphomas and to our knowledge, gastrointestinal lymphoma involving 2 different regions in the GI tract has not been discussed in the literature. Herein, we are presenting a rare case of diffuse large B-cell lymphoma presenting as a malignant mass in both the duodenum and ascending colon.

Schizencephaly as an Unusual Cause of Adult-Onset Epilepsy: A Case Report.

Schizencephaly is a very rare anatomical malformation of the cerebrum characterized by a cleft extending from the cortex to the ventricles. Usually, this disease is diagnosed at a very young age or in early adulthood. Symptoms may vary depending on the site and the size of the malformation. Here, we are describing the unique case of a 21-year-old female, with a past medical history of migraine-type headaches, who presented after the first-onset seizure and was found to have open-lip schizencephaly. She was started on levetiracetam with no complications. In this report, we are trying to describe the proposed etiology and discuss the typical clinical presentation of schizencephaly and compare it to our adult patient who survived childhood without significant cognitive or neurological impairment.

Severe Gastroparesis Flare: Is COVID-19 the Inciting Factor?

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has emerged as a public health hazard. It is commonly associated with respiratory symptoms including fever, cough and sore throat. Viral infections have historically been implicated in the exacerbations of gastrointestinal (GI) disorders. Coronavirus disease 2019 (COVID-19) has been associated with GI manifestations including diarrhea and vomiting. However, exacerbation of underlying functional GI disorders has been rarely reported with SARS-CoV-2 infection. Herein we report a case of a 31-year-old female with acute gastroparesis flare secondary to COVID-19 which was refractory to pharmacological therapy.

A rare case of marijuana associated with ascending aorta thrombosis complicated with stroke and bilateral renal infarcts.

Ascending aortic is an uncommon site for arterial thrombosis and ascending aortic thrombosis is a very rare phenomenon with a high fatality rate. Marijuana is the most commonly used psychoactive drug in the United States and a few cases have been reported on the association of marijuana with vascular thromboembolism. However, the pathophysiology and exact mechanism are still not well studied. Herein, we present a case of a 44-year-old female with active marijuana use presented with ascending aortic thrombus associated with acute arterial occlusion of the right vertebral artery and bilateral renal artery. The unique part of this case is that the patient did not have the classical risk factors for vascular thromboembolic disease. The only risk factor was marijuana smoking. To our best knowledge, this is one of the unique cases of marijuana-associated with ascending aorta thrombosis.

Unusual Presentation of Post-coital Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is a grave medical condition that is defined as a separation of the coronary artery wall layer. This presentation is rare in males and can be triggered by cardio-circulatory stress, such as exercise and emotional stress. Sexual intercourse is considered potent cardiovascular stress that can be strenuous and cause rapid and significant changes in the heart rate and blood pressure which can predispose SCAD. Herein, we are reporting a very rare case of a 41-year-old male gentleman who presented with SCAD after vigorous sexual intercourse. We are reporting this case to encourage physicians to educate their patients on the topic.

Unique Communication: A Case Report of Acquired Esophageal Pulmonary Fistula.

Esophageal respiratory fistula represents a connection between esophagus and the respiratory system. Esophageal tracheal and esophageal bronchial fistulas are common whereas esophageal pulmonary fistula is rarely seen. We report a case of esophageal pulmonary fistula in a middle aged African American male with a history of bronchoesophageal fistula who presented with pneumonia. The diagnosis was confirmed with fluoroscopy esophagram. Management with endoscopic stent placement was planned however the patient refused treatment. A diagnosis of esophageal pulmonary fistula should be kept in mind for patients with pulmonary symptoms and dysphagia. Early diagnosis and treatment are required to prevent complications and improve quality of life in these patients.