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BACKGROUND AND AIMS: Biliary drainage is vital in managing malignant biliary obstruction (MBO). Suprapapillary stenting has emerged as a viable alternative to transpapillary stenting and is performed using inside plastic (iPS) or metal stents (iMS). This meta-analysis aims to evaluate the outcomes of suprapapillary stent placement for MBO. METHODS: The Embase, PubMed, and Web of Science databases were systematically searched to include all studies published before September 31, 2023, that reported on the outcomes of suprapapillary stents placed for MBO. Using the random-effect model, the pooled, weight-adjusted event rate estimate for the clinical outcomes was calculated with 95% confidence intervals (CIs). RESULTS: Twenty-eight studies were included, with a total of 1401 patients. The pooled clinical success rate was 98.9%. A subgroup analysis yielded non-significant differences between the iPS and iMS groups (99.3% vs. 98.6%, respectively; P = 0.44). The pooled incidence rate of adverse events (AE) with suprapapillary stents was 9.5%. In a subgroup analysis, the incidence of AEs with iPS was 10.7% compared to 9% in the iMS group without a statistical difference (P = 0.32). The most common adverse event was cholangitis (2.2%), followed by pancreatitis (1.1%), cholecystitis (0.5%), and bleeding (0.12%). CONCLUSION: When technically feasible, suprapapillary stenting for MBO is a viable endoscopic option with a high clinical success rate and acceptable adverse event rates. Both iPS and iMS exhibit similar efficacy.
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Colestase , Plásticos , Stents , Humanos , Colestase/cirurgia , Colestase/etiologia , Stents/efeitos adversos , Metais , Neoplasias dos Ductos Biliares/complicações , Neoplasias dos Ductos Biliares/cirurgia , Drenagem/métodos , Drenagem/instrumentação , Resultado do TratamentoRESUMO
Background/Objectives: Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has emerged as an alternative option for biliary drainage in cases of failed endoscopic retrograde cholangiopancreatography (ERCP). Limited data exist on the safety and efficacy of EUS-HGS. In this comprehensive meta-analysis, we aim to study the safety and efficacy of EUS-HGS in cases of failed conventional ERCP. Methods: Embase, PubMed, and Web of Science databases were searched to include all studies that evaluated the efficacy and safety of EUS-HGS. Using the random effect model, the pooled weight-adjusted event rate estimate for clinical outcomes in each group were calculated with 95% confidence intervals (CIs). The primary outcomes were technical and clinical success rates. Secondary outcomes included overall adverse events (AEs), rates of recurrent biliary obstruction (RBO), and rates or re-intervention. Results: Our analysis included 70 studies, with a total of 3527 patients. The pooled technical and clinical success rates for EUS-HGS were 98.1% ([95% CI, 97.5-98.7]; I2 = 40%) and 98.1% ([95% CI, 97.5-98.7]; I2 = 40%), respectively. The pooled incidence rate of AEs with EUS-HGS was 14.9% (95% CI, 12.7-17.1), with bile leakage being the most common (2.4% [95% CI, 1.7-3.2]). The pooled incidence of RBO was 15.8% [95% CI, 12.2-19.4], with a high success rate for re-intervention (97.5% [95% CI, 94.7-100]). Conclusions: Our analysis showed high technical and clinical success rates of EUS-HGS, making it a feasible and effective alternative to ERCP. The ongoing development of dedicated devices and techniques is expected to make EUS-HGS more accessible and safer for patients in need of biliary drainage.
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INTRODUCTION: Esophageal Stents are used to maintain esophageal lumen patency in esophageal strictures caused by intrinsic and/or extrinsic malignancies and the occlusion of concomitant esophageal fistulas. While data on the efficacy and safety of esophageal stents exist, comprehensive evaluation of adverse events is limited. The aim of this study is to investigate the reported adverse events and device failures associated with esophageal self-expandable metal stents (SEMS) using the FDA's Manufacturer and User Facility Device Experience (MAUDE) database. METHODS: Post-marketing surveillance data for the esophageal SEMSs were analyzed using the FDA's MAUDE database from January 2014 to December 10, 2023. The outcomes of interest were patient-related adverse events and device failures. Statistical analysis was performed using Microsoft Excel 2010 and SPSS. Pooled numbers and percentages were calculated for each adverse event. Continuous variables underwent analysis using a two-tailed student t test, and significance was set to p ≤ 0.05. RESULTS: During the study period, 548 MAUDE reports revealed 873 device failures and 186 patient-related adverse events. The most common device issues were stent activation, positioning, or separation problems (4 n = 403; 46.2%), followed by device detachment or migration (n = 109, 12.5%), and material problems (n = 93, 10.7%). Patient complications included dysphagia/odynophagia (10%), perforation, pain, and bleeding (each 7.6%). The most common device failures in over-the-wire (OTW) stents and through-the-scope (TTS) stents were activation, positioning, or separation problems (TTS: n = 183, 52.6% vs OTW: n = 220, 41.9%). Compared to OTW stents, TTS stents had higher migration and breakage (13.5% vs. 11.8%, p = 0.24), and (9.2% vs. 6.7%, p = 0.08) respectively, while OTW stents had more challenges with stent advancement or removal (5.1% vs. 0.3%, p < 0.001 and 4.6% vs 3.4%, p = 0.19, respectively) and material problems (14.7% vs. 4.6%, p < 0.001). Activation, positioning, and separation problems were the most frequent device failures in fully covered (FC) and partially covered (PC) stents (FC: n = 62, 32.8%, PC: n = 168, 43.5%). FC stents had higher migration rates (20.6% vs 9.8%, p < 0.001), while PC stents exhibited more material problems (17.4% vs. 5.8%, p < 0.001) and difficulties with advancing the stents (6.7% vs. 0%, p < 0.001). CONCLUSION: Our examination showed a prevalence of reported device complications associated with stent activation, positioning, and separation problems. Dysphagia or odynophagia emerged as the most frequently reported patient complication. Furthermore, our analysis, provides insights into TTS vs. OTW and FC vs. PC esophageal SEMSs, enabling endoscopists and manufacturers to better understand adverse events and potentially optimize device design for future iterations.
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Bases de Dados Factuais , Vigilância de Produtos Comercializados , Falha de Prótese , Stents Metálicos Autoexpansíveis , United States Food and Drug Administration , Humanos , Stents Metálicos Autoexpansíveis/efeitos adversos , Estados Unidos/epidemiologia , Estenose Esofágica/etiologia , Estenose Esofágica/terapiaRESUMO
Background: Data detailing the risk of Venous Thromboembolism (VTE) subtypes among individuals with Inflammatory bowel disease (IBD) remain limited.Aims: We looked to assess the odds of VTE subtypes among hospitalized individuals with IBD as compared to those without IBD. Materials & Methods: Using the Nationwide Inpatient Sample database, we applied a multivariable regression analysis to compare the odds of primary VTE-related hospitalizations among individuals with and without IBD from 2016 to 2020, including deep venous thrombosis (DVT), pulmonary embolism (PE), portal vein thrombosis (PVT), Budd Chiari syndrome (BCS), renal vein thrombosis (RVT), and cerebral venous sinus thrombosis (CVST). Results: Overall, there were 15,565 primary VTE-related hospitalizations among individuals with IBD, as compared to 1,449,164 among individuals without IBD. Having IBD increased the odds for DVT (aOR = 1.34, 95%CI: 1.25-1.43), PVT (aOR = 3.16, 95%CI: 2.65-3.76), and CVST (aOR=1.45, 95%CI: 1.05-2.00), without significant increase in the odds of a PE, BCS, or RVT. Further, individuals with ulcerative colitis (UC) were at a higher risk for the majority of VTE-subtypes as compared to those with Crohn's disease (CD). Among individuals with a VTE-related hospitalization, the presence of IBD was not associated with increased mortality (aOR = 0.77, 95%CI: 0.40-1.50), but was associated with an increased length of stay (CD - 4.8 days, UC - 5.3 days, without IBD - 4.3 days, p<0.01). Conclusions: Clinicians should retain a high index of suspicion when evaluating VTE-related symptoms among individuals with IBD, as the presence of IBD confers a higher risk of DVT, PVT and CVST related-hospitalizations, and longer stays as compared to individuals without IBD.
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Limited objective data exist on the comparison of post-endoscopic retrograde cholangiopancreatography (ERCP) complications in patients with cirrhosis based on the severity of the disease. We evaluated the effectiveness of the Child-Turcotte-Pugh (CTP) score system in anticipating the risk of post-ERCP complications in patients with cirrhosis. The PubMed, Scopus, Embase, and Cochrane databases were searched from inception through September 2022 to identify studies comparing post-ERCP complications in patients with cirrhosis based on CTP score. Odds ratios (ORs) and their associated 95% CIs were pooled using a random-effect model to calculate effect size. The reference group for analysis was the CTP class C patient group. Seven studies comprising 821 patients who underwent 1068 ERCP procedures were included. The CTP class C patient population exhibited a higher risk of overall post-ERCP adverse events compared with those with class A or B (OR: 2.87, 95% CI: 1.77-4.65, P = 0.00 and OR: 2.02, 95% CI: 1.17-3.51, P = 0.01, respectively). Moreover, CTP class B patients had a significantly higher complication rate than CTP class A patients (OR: 1.62, 95% CI: 1.04-2.53, P = 0.03). However, no statistically significant differences were found in the occurrence of specific types of complications, including bleeding, pancreatitis, cholangitis, perforation, or mortality across the three CTP groups. We demonstrated that the CTP classification system is a reliable predictor of ERCP complications in patients with cirrhosis. Consequently, caution should be exercised when performing ERCP in patients classified as CTP class C.
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Colangiopancreatografia Retrógrada Endoscópica , Cirrose Hepática , Índice de Gravidade de Doença , Humanos , Cirrose Hepática/complicações , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/epidemiologia , Medição de Risco/métodosRESUMO
Purpose: To compare the risks of adverse outcomes, including mortality, gastrointestinal bleeding, and venous thromboembolism, between COVID-19 patients with inflammatory bowel disease (IBD) and those without IBD. Methods: We analyzed data from the National Inpatient Sample between January and December 2020. The study included adult patients with Crohn's disease (CD) and ulcerative colitis (UC) who contracted COVID-19. Inpatient outcomes were compared between the IBD and non-IBD COVID-19 cohorts. Results: Out of 1,050,045 COVID-19 hospitalizations, 0.28% had CD (2954 patients) and 0.26% had UC (2794 patients). After adjusting for confounding factors, UC patients had a significantly higher risk of deep vein thrombosis compared to non-IBD patients, with an adjusted odds ratio (aOR) of 2.55 (P < 0.001). However, CD patients did not show a significant association with deep vein thrombosis (aOR 1.29, P = 0.329). There were no significant associations between IBD patients (both UC and CD) and pulmonary embolism, nonvariceal gastrointestinal bleeding, or in-hospital mortality. UC patients had a longer average hospital stay (8.25 days) compared to non-IBD patients (adjusted mean difference 0.89, P = 0.007). Healthcare resource utilization was similar among the three groups. Conclusion: Our national study on COVID-19 hospitalizations indicates that patients with IBD have comparable rates of gastrointestinal bleeding, pulmonary embolism, and mortality as those without IBD. However, patients with UC hospitalized with COVID-19 have a higher risk of deep vein thrombosis than COVID-19 patients hospitalized without UC. Further research is needed to better understand the relationship between COVID-19 and IBD.
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Background: The career trajectory of medical professionals, particularly in specialized fields like gastroenterology, can significantly impact healthcare and research. This study aimed to analyze career choices among gastroenterology fellows in the US and investigate the factors influencing these choices. Methods: We utilized data from the American Medical Association on internal medicine subspecialty fellows. The study examined career plans of gastroenterology fellows and compared them with those of other subspecialties. A chi-square test was performed to assess differences in career choices and practice settings. Results: Among gastroenterology fellows, 46% opted for private practice, 28% pursued further training, and 26% chose academia. Notably, gastroenterology fellows were more inclined toward private practice than their counterparts in other subspecialties (46.3% vs 38.4%) and were less likely to pursue academic careers (25.6% vs 30.7%). Conclusion: This study highlights a concerning trend among recent gastroenterology fellowship graduates favoring private practice over academic careers or additional training. To sustain and strengthen academic medicine in gastroenterology, interventions such as scholarships, mentorship programs, and loan repayment initiatives tailored to academic pursuits could play a crucial role.
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INTRODUCTION: Cyclical vomiting syndrome (CVS) carries a significant financial burden on the U.S. healthcare system due to the recurrent emergency department visits and inpatient hospitalizations. We aimed to update the literature on the predictors of hospital utilization and readmission among individuals admitted with CVS. METHODS: This is a retrospective nationwide study of patients hospitalized with a primary diagnosis of CVS. Using weighted data from the National Inpatient Sample (NIS) and the National Readmission Database (NRD), we conducted a multivariate regression analysis to assess predictors of length of stay (LOS), and 30-day readmission. RESULTS: Primary admissions for CVS totaled 35,055 in the NIS, and 31,240 in the NRD. 2012 patients (6.4%) were readmitted within 30 days. On multivariate regression, cannabis use was associated with reduced LOS (adjusted Mean Difference (aMD) = -0.53 days, 95% CI: -0.68 to -0.38), and 30-day readmissions (adjusted Hazard Ratio (aHR) = 0.63, 95% CI: 0.54-0.73). DISCUSSION: Cannabis use among CVS admissions was associated with reduced LOS and 30-day readmissions; these results could be in fact driven by Cannabis Hyperemesis Syndrome (CHS)-related hospitalizations and the effect of cannabis cessation on decreased symptomatology. ICD-10 coding for CHS should be transitioned to specific codes to improve the differentiation between CVS and CHS-related hospitalizations.
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Síndrome da Hiperêmese Canabinoide , Cannabis , Humanos , Estudos Retrospectivos , Vômito/etiologia , HospitalizaçãoRESUMO
GOALS: To investigate the outcomes of hospitalized patients with gastric antral vascular ectasia (GAVE) in the setting of aortic stenosis (AS). BACKGROUND: Although AS is associated with gastrointestinal arteriovenous malformations, its association with GAVE, a rare cause of upper gastrointestinal bleeding, remains unknown. STUDY: The National Inpatient Sample database from the years 2016 to 2019 was searched for patients admitted with a diagnosis of GAVE, with and without a history of AS. Univariate and multivariate logistic regression analysis was performed to determine the risk of mortality and in-hospital complications in the GAVE/AS group compared with the GAVE-only group. RESULTS: Patients with AS had a 2-fold increase in the risk of GAVE [odds ratio (OR): 2.08, P < 0.001], with no statistically significant difference in inpatient mortality between the study groups (OR: 1.36, P = 0.268). Patients with GAVE-AS had a higher risk of hypovolemic shock (OR: 2.00, P = 0.001) and acute coronary syndromes (OR: 2.25, P < 0.001) with no difference in risk of cardiogenic shock (P = 0.695), acute kidney injury (P = 0.550), blood transfusion (P = 0.270), sepsis (P = 0.598), respiratory failure (P = 0.200), or in-hospital cardiac arrest (P = 0.638). The cost of care in patients with GAVE-AS was increased by a mean of $4729 (P = 0.022), with no increase in length of stay (P = 0.320) when compared with patients with GAVE-only. CONCLUSIONS: Patients with AS have a 2-fold increase in the risk of development of GAVE. Patients with AS admitted for GAVE-related bleeding are at higher rates of hypovolemic shock, acute coronary syndrome, and higher resource utilization when compared with admitted patients with GAVE without AS.
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INTRODUCTION: Previous research identified AIH as linked to unfavorable obstetrical outcomes in a US nationwide retrospective study from 2012-2016. Our aim is to update the literature and strengthen the AIH-pregnancy outcomes relationship. METHODS: Using the National Inpatient Sample database in the US, from 2016 to 2020, we compared pregnant females with a diagnosis of AIH to those with and without other chronic liver diseases (CLD), using ICD-10-CM codes. Baseline characteristics were analyzed using T-test and Chi-Square, and multivariate regression was used to estimate the differences in maternal outcomes adjusted for age, race, insurance status, geographical location, hospital characteristics, and comorbid conditions. RESULTS: Out of 19,392,328 hospitalizations for pregnant females ≥ 18 years old from 2016 to 2020, 1095 had AIH, 179,655 had CLD, and 19,206,696 had no CLD. No mortality was observed among individuals with AIH. When compared to individuals without CLD, AIH was associated with an 82% increase in the odds of preterm delivery (AIH: 8% vs. Without CLD: 5%, adjusted Odds Ratio = 1.82, 95% CI 1.06-3.14), with no significant differences in gestational diabetes mellitus, hypertensive complications, and postpartum hemorrhage, and a 0.6 day longer hospital stay. Furthermore, there were no significant differences in outcomes between AIH and CLD. CONCLUSIONS: Our study reinforces the association of AIH with adverse obstetrical outcomes (e.g., preterm delivery), however, we found that there is no difference in GDM and hypertensive complications, as suggested in prior studies. Therefore, further investigations are needed to clarify the association between AIH and these obstetrical complications.
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Hepatite Autoimune , Hepatopatias , Nascimento Prematuro , Gravidez , Feminino , Recém-Nascido , Humanos , Adolescente , Hepatite Autoimune/diagnóstico , Hepatite Autoimune/epidemiologia , Hepatite Autoimune/complicações , Estudos Retrospectivos , Nascimento Prematuro/epidemiologia , Hepatopatias/complicações , HospitalizaçãoRESUMO
OBJECTIVES: To examine the predictors and outcomes associated with the development of acute pancreatitis (AP) in patients hospitalized with Coronavirus Disease 2019 (COVID-19). METHODS: This is an observational analysis of the 2020 National Inpatient Sample Database. The study includes adult patients who were admitted with a confirmed diagnosis of COVID-19 and stratifies them based on the presence or absence of AP during their hospitalization. Predictors of AP development between the two groups and differences in outcomes are examined. Multivariate logistic regression analysis using Stata/BE 17.0 is conducted, with adjustments made for age, sex, race, and Charlson Comorbidity Index (CCI). Statistical significance is determined at a p-value of <0.05. RESULTS: Significant factors associated with an increased risk of AP in COVID-19 patients include Hispanic ethnicity, higher Charlson Comorbidity Index (CCI) score, residence in states located in the southern region, history of chronic kidney disease, chronic liver disease, malnutrition, portal hypertension, and alcohol use. COVID-19 patients who developed AP were also found to be at higher risk of adverse outcomes, including mortality, acute coronary syndrome, acute kidney injury, sepsis, septic shock, in-hospital cardiac arrest, invasive mechanical ventilation, upper gastrointestinal bleeding, prolonged length of stay, and increased healthcare cost. CONCLUSIONS: In hospitalized patients with COVID-19, the presence of AP is associated with increased mortality and morbidity. Risk factors for developing AP in this population include Hispanic ethnicity, residence in the southern region, higher Charlson Comorbidity Index (CCI) score, history of chronic kidney disease, chronic liver disease, malnutrition, portal hypertension, and alcohol use.
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COVID-19 , Hipertensão Portal , Desnutrição , Pancreatite , Insuficiência Renal Crônica , Adulto , Humanos , Pancreatite/epidemiologia , Pancreatite/terapia , Pancreatite/complicações , COVID-19/epidemiologia , COVID-19/terapia , COVID-19/complicações , Pandemias , Doença Aguda , Hospitalização , Desnutrição/complicações , Hipertensão Portal/complicações , Hipertensão Portal/epidemiologia , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/epidemiologia , ComorbidadeRESUMO
BACKGROUND: Previous studies have demonstrated a disparity in liver transplantation (LT) for hepatocellular carcinoma (HCC) among races in the United States (U.S.). AIMS: We aimed to update the literature on the odds, trends, and complications of LT in the treatment of hepatocellular carcinoma (HCC), among individuals of different racial backgrounds. METHODS: This is a nationwide study of adult individuals admitted for LT with a primary diagnosis of HCC. Using weighted data from the National Inpatient Sample (NIS) database, we compared the odds of LT among different races from 2016 to 2020, using a multivariate regression analysis. We further assessed the trends and outcomes of LT among races. RESULTS: A total of 112,110 adult were hospitalized with a primary diagnosis of HCC. 3020 underwent LT. When compared to Whites, the likelihood of undergoing LT for HCC was significantly reduced in Blacks (OR = 0.60, 95% CI = 0.46-0.78). Further, Blacks had increased mortality rates (7% in Blacks vs. 1% in Whites, p < 0.001), sepsis (11% in Blacks vs. 3% in Whites, p = 0.015), and acute kidney injury (AKI) (54% in Blacks vs. 31% in Whites, p < 0.001) following LT. CONCLUSIONS: Individuals identifying as Blacks were less likely to undergo LT for HCC, and more likely to develop complications. Further initiatives are warranted to mitigate the existing disparities among racial groups.
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Carcinoma Hepatocelular , Neoplasias Hepáticas , Transplante de Fígado , Adulto , Humanos , Estados Unidos/epidemiologia , Carcinoma Hepatocelular/patologia , Neoplasias Hepáticas/patologia , Transplante de Fígado/efeitos adversos , Etnicidade , Grupos Raciais , Estudos RetrospectivosRESUMO
BACKGROUND Vanishing lung syndrome (VLS), also known as idiopathic giant bullous emphysema, is a rare manifestation of chronic obstructive pulmonary disease (COPD) and usually occurs in middle-aged smokers. This report presents a 58-year-old female smoker with COPD and VLS who presented with spontaneous pneumothorax. The pneumothorax was managed with a chest tube and was later complicated by massive subcutaneous emphysema. CASE REPORT A 58-year-old woman with a past medical history of long-term smoking and COPD presented with worsening shortness of breath. Upon initial evaluation, she had tachypnea and hypoxia (SpO2 93%). Chest radiography revealed a new right-sided pneumothorax on top of extensive bullous disease, which the patient already had. The drainage of the pneumothorax was successful with a pigtail catheter. However, during the following night, after insertion of the pigtail catheter, the patient developed massive subcutaneous emphysema, which was confirmed with imaging. The patient remained hemodynamically stable, and diffuse subcutaneous crepitus was present on examination. The pigtail catheter was repositioned, resulting in complete resolution of the subcutaneous emphysema in the following 2 weeks. CONCLUSIONS This case highlights the importance of a timely diagnosis and management of the possible presentations and complications of VLS. Complications such as pneumothorax are life-threatening and require urgent management, taking precedence over the curative treatment for VLS, surgical bullectomy.
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Pneumotórax , Doença Pulmonar Obstrutiva Crônica , Enfisema Pulmonar , Enfisema Subcutâneo , Feminino , Pessoa de Meia-Idade , Humanos , Pneumotórax/diagnóstico por imagem , Pneumotórax/etiologia , Pneumotórax/terapia , Fumantes , Enfisema Pulmonar/complicações , Enfisema Subcutâneo/etiologia , Enfisema Subcutâneo/terapia , Síndrome , PulmãoRESUMO
Background Recent studies have shown an increased risk of diabetes mellitus in patients with Inflammatory bowel disease. However, the impact of IBD on outcomes of patients with diabetic ketoacidosis remains unknown. Methods This is an observational analysis of the National Inpatient Sample Database. The authors identified patients with a diagnosis of diabetic ketoacidosis and inflammatory bowel diseases. Outcomes studied were differences in risk of mortality, in-hospital outcomes and healthcare resources utilization. Multivariate logistic analysis was performed and results were adjusted for patient and hospital characteristics and comorbidities. Results No significant difference in mortality was observed in the DKA-IBD group when compared to the DKA-only group (aOR 0.55, p = 0.560). Similarly, inflammatory bowel disease had no impact on risk of sepsis (aOR 1.06, p = 0.742), acute kidney injury (aOR 1.08, p = 0.389), acute coronary syndrome (aOR 0.70, p = 0.397), ischemic stroke (aOR 1.53, p = 0.094), acute respiratory failure (aOR 1.00, p = 0.987), invasive mechanical ventilation (aOR 0.54, p = 0.225), deep vein thrombosis (aOR 1.68, p = 0.275), pulmonary embolism (aOR 2.16, p = 0.279) or cardiac arrest (aOR 1.35, p = 0.672) in diabetic ketoacidosis patients. The study group had a significant increase in length of stay (adjusted mean difference 0.63, p = 0.002) and charge of care (adjusted mean difference 3,950$, p = 0.026). Conclusion Inflammatory bowel disease is not associated with risk difference in mortality or morbidity in admitted patients with diabetic ketoacidosis, however, it does contribute to increased healthcare resources utilization.
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BACKGROUND Diffuse large B cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma (NHL). While bone marrow (BM) involvement is common in lymphoma, primary bone marrow (PBM) DLBCL is extremely rare. We present a case of PBM DLBCL discovered in a patient with COVID-19. CASE REPORT An 80-year-old man presented with generalized abdominal pain, weight loss, fever, fatigue, anorexia, and watery diarrhea over a 3-month period. Physical examination was unremarkable. Laboratory workup revealed anemia, thrombocytopenia, and elevated inflammation markers. SARS-COV-2 PCR was positive, while blood cultures were negative. A rapid decline in the white blood cell count in the following days prompted a BM biopsy, confirming the diagnosis of PBM DLBCL. Computed tomography (CT) did not show thoracic or abdominal lymphadenopathy. The patient received packed red blood cell and platelet transfusions, granulocyte colony-stimulating factor (G-CSF) for pancytopenia, and empirical antibiotics for suspected infection. Due to active COVID-19 and advanced age, cytotoxic chemotherapy was delayed. Rituximab and prednisone were initiated on day 9, followed by an infusion reaction, which led to treatment discontinuation. He died 2 days later. CONCLUSIONS Diagnosing PBM malignancy is challenging, especially with coexisting infection. It is essential to suspect underlying BM malignancy in patients with clinical deterioration and worsening pancytopenia despite adequate treatment. The diagnosis of PBM DLBCL requires the absence of lymphadenopathy, and the presence of histologically confirmed DLBCL. Prompt management with combination chemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) with/without hematopoietic stem cell transplant can improve the prognosis.
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COVID-19 , Linfadenopatia , Linfoma Difuso de Grandes Células B , Pancitopenia , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Medula Óssea/patologia , COVID-19/complicações , Ciclofosfamida/uso terapêutico , Doxorrubicina/uso terapêutico , Fator Estimulador de Colônias de Granulócitos/uso terapêutico , Humanos , Linfadenopatia/patologia , Linfoma Difuso de Grandes Células B/complicações , Linfoma Difuso de Grandes Células B/diagnóstico , Linfoma Difuso de Grandes Células B/terapia , Masculino , Pancitopenia/etiologia , Prednisona/uso terapêutico , Rituximab/uso terapêutico , SARS-CoV-2 , Vincristina/uso terapêuticoRESUMO
BACKGROUND Adrenocortical carcinoma (ACC) is a very rare disease, with an incidence of 1.02 per million population per year. The most commonly secreted hormone in ACC is cortisol, often presenting as a rapidly progressive Cushing syndrome (CS). We describe a case of ACC with an unusual presentation, mainly with psychiatric manifestations, including panic attacks and hallucinations. CASE REPORT A 52-year-old woman presented with episodes of acute anxiety, hallucinations, palpitations, hot flashes, gastrointestinal upset associated with paroxysmal hypertension, tachycardia, and flushing for 1 week. The initial workup was aimed at ruling out causes of acute psychosis and/or anxiety such as substance use, and organic diseases such as pheochromocytoma (PCC). Our initial suspicion of PCC was ruled out based on the negative serum and urinary metanephrines (MN) and normetanephrines (NMN). Recurrent metabolic alkalosis and hypokalemia despite fluid and potassium supplementation prompted us to work up for hyperaldosteronism. Her renin level was elevated and the aldosterone level was appropriately suppressed. Elevated cortisol, positive dexamethasone (DXM) suppression test, low adrenocorticotropic hormone (ACTH), imaging revealing an adrenal mass, and postoperative histology confirmed the diagnosis of cortisol-producing ACC. CONCLUSIONS It is essential to recognize psychiatric presentations of CS to achieve early diagnosis and prevent mortality and morbidity. Panic attacks, a common presentation of CS, can present with features mimicking pheochromocytoma (PCC), including palpitations, sweating, tachycardia, and paroxysmal hypertension. A comprehensive workup is warranted to reach a diagnosis, with a combination of hormonal levels, imaging, and histology.