Severe small intestinal bacterial overgrowth syndrome after jejunal feeding requiring surgical intervention: a case report and review of the literature.

BACKGROUND: Small intestinal bacterial overgrowth (SIBO) is a condition of unknown prevalence characterized by an excessive amount of bacteria in the small bowel, typically resulting in vague gastrointestinal symptoms with bloating being most commonly reported. Here we describe a severe case of SIBO leading to small bowel necrosis requiring surgical intervention. CASE PRESENTATION: A 55-year-old Hispanic female with gastric outlet obstruction secondary to a newly diagnosed gastric adenocarcinoma, receiving neoadjuvant chemotherapy, developed bloody gastrostomy output and rapidly progressing nausea and abdominal distention 3 days after jejunostomy tube placement and initiation of jejunal enteral nutrition. Imaging revealed diffuse pneumatosis and portal venous gas. Surgical exploration confirmed segmental bowel necrosis requiring resection. Histologic findings were consistent with SIBO. CONCLUSIONS: Presentation of severe SIBO in the setting of intestinal stasis secondary to gastric outlet after initiation of enteral feeds is a rare phenomenon. Early recognition and diagnosis of SIBO is critical in minimizing patient morbidity and mortality.

The Emergence of Zoonotic Onchocerca lupi Infection in the United States--A Case-Series.

This case-series describes the 6 human infections with Onchocerca lupi, a parasite known to infect cats and dogs, that have been identified in the United States since 2013. Unlike cases reported outside the country, the American patients have not had subconjunctival nodules but have manifested more invasive disease (eg, spinal, orbital, and subdermal nodules). Diagnosis remains challenging in the absence of a serologic test. Treatment should be guided by what is done for Onchocerca volvulus as there are no data for O. lupi. Available evidence suggests that there may be transmission in southwestern United States, but the risk of transmission to humans is not known. Research is needed to better define the burden of disease in the United States and develop appropriately-targeted prevention strategies.

Identification of acute HIV infection using fourth-generation testing in an opt-out emergency department screening program.

STUDY OBJECTIVE: Acute HIV infection is a clinical diagnosis aided by technology. Detecting the highly infectious acute stage of HIV infection is critical to reducing transmission and improving long-term outcomes. The Maricopa Integrated Health System implemented nontargeted, opt-out HIV screening with a fourth-generation antigen/antibody combination HIV assay test in our adult emergency department (ED) at Maricopa Medical Center to assess the prevalence of both acute and chronic unrecognized HIV. METHODS: Eligible patients aged 18 to 64 years were tested for HIV if they did not opt out and had blood drawn as part of their ED care. Patients were not eligible if they had a known HIV or AIDS diagnosis, exhibited altered mental status, were a current resident of a long-term psychiatric or correctional facility, or prompted a trauma activation. Reactive test results were delivered by a physician with the assistance of a linkage-to-care specialist. Specimens with a reactive fourth-generation assay result underwent confirmatory testing. RESULTS: From July 11, 2011, through January 5, 2014, 27,952 HIV screenings were performed for 22,468 patients tested for HIV; 78 (0.28%) had new HIV diagnoses. Of those, 18 (23% of all new diagnoses) were acute HIV infections, and 22 patients (28%) had a CD4 count of less than 200 cells/mL, or an opportunistic infection. CONCLUSION: HIV testing with a fourth-generation antigen/antibody laboratory test producing rapid results is feasible in an ED. Unexpectedly, nearly one fourth of patients with undiagnosed HIV had acute infections, which would have been more difficult to detect with previous testing technology.

SARS-CoV-2 Infects Human Engineered Heart Tissues and Models COVID-19 Myocarditis.

There is ongoing debate as to whether cardiac complications of coronavirus disease-2019 (COVID-19) result from myocardial viral infection or are secondary to systemic inflammation and/or thrombosis. We provide evidence that cardiomyocytes are infected in patients with COVID-19 myocarditis and are susceptible to severe acute respiratory syndrome coronavirus 2. We establish an engineered heart tissue model of COVID-19 myocardial pathology, define mechanisms of viral pathogenesis, and demonstrate that cardiomyocyte severe acute respiratory syndrome coronavirus 2 infection results in contractile deficits, cytokine production, sarcomere disassembly, and cell death. These findings implicate direct infection of cardiomyocytes in the pathogenesis of COVID-19 myocardial pathology and provides a model system to study this emerging disease.

Intraoperative touch imprint and frozen section analysis of sentinel lymph nodes after neoadjuvant chemotherapy for breast cancer.

OBJECTIVE: To evaluate the accuracy of touch imprint and frozen section analysis of sentinel nodes after neoadjuvant chemotherapy. SUMMARY BACKGROUND DATA: Intraoperative evaluation of the sentinel node can determine the need for axillary dissection at the time of initial operation and therefore spare the patient a second operation. Little data, however, exists on the accuracy of intraoperative evaluation of sentinel nodes after neoadjuvant chemotherapy. METHODS: A retrospective chart review was performed of all sentinel node procedures for breast cancer from 2004 to 2008 at a single institution. The sentinel node procedure was done before (no-NACT) chemotherapy in 107 patients and 37 had the procedure after neoadjuvant (NACT) chemotherapy. Intraoperative analysis of sentinel nodes was performed using touch imprint and frozen section techniques. RESULTS: In the no-NACT group, intraoperative assessment by touch imprint analysis had 61% sensitivity, 100% specificity, and 87% accuracy. Frozen section analysis was similar with 74% sensitivity, 100% specificity, and 90% accuracy. In the NACT group, touch imprint analysis had 79% sensitivity, 100% specificity, and 90% accuracy. Frozen section analysis was again similar with 74% sensitivity, 100% specificity, and 83% accuracy. When the no-NACT group and the NACT group were compared, both frozen section and touch imprint analysis had similar sensitivity, specificity, and accuracy. CONCLUSIONS: Intraoperative evaluation of sentinel nodes with touch imprint and frozen section analysis in patients treated with neoadjuvant chemotherapy showed acceptable sensitivity, specificity, and accuracy. Nearly all of the misses in intraoperative evaluation were in patients with micrometastases.

SARS-CoV-2 Infects Human Engineered Heart Tissues and Models COVID-19 Myocarditis.

Epidemiological studies of the COVID-19 pandemic have revealed evidence of cardiac involvement and documented that myocardial injury and myocarditis are predictors of poor outcomes. Nonetheless, little is understood regarding SARS-CoV-2 tropism within the heart and whether cardiac complications result directly from myocardial infection. Here, we develop a human engineered heart tissue model and demonstrate that SARS-CoV-2 selectively infects cardiomyocytes. Viral infection is dependent on expression of angiotensin-I converting enzyme 2 (ACE2) and endosomal cysteine proteases, suggesting an endosomal mechanism of cell entry. After infection with SARS-CoV-2, engineered tissues display typical features of myocarditis, including cardiomyocyte cell death, impaired cardiac contractility, and innate immune cell activation. Consistent with these findings, autopsy tissue obtained from individuals with COVID-19 myocarditis demonstrated cardiomyocyte infection, cell death, and macrophage-predominate immune cell infiltrate. These findings establish human cardiomyocyte tropism for SARS-CoV-2 and provide an experimental platform for interrogating and mitigating cardiac complications of COVID-19.

Nasal-type NK/T-cell lymphoma presenting as hemophagocytic syndrome in an 11-year-old Mexican boy.

Recently established by the World Health Organization classification, "nasal" and "nasal-type" NK/T-cell lymphoma arise from natural killer (NK) cells. They have distinct clinicopathologic features, specific genotype and phenotype, and a high association with Epstein-Barr virus infection. Nasal-type NK/T-cell lymphoma arise from extranasal sites including skin, soft tissue, gastrointestinal tract, liver, spleen, testes, lung, and central nervous system. Most cases are reported from Asia and South America in adults. There are very few cases reported in the pediatric age group. We report an 11-year-old child with extranodal nasal-type NK/T-cell lymphoma presenting as hemophagocytic syndrome and multiorgan system failure with fatal outcome.

Zoonotic Onchocerca lupi infection in a 22-month-old child in Arizona: first report in the United States and a review of the literature.

A 22-month-old girl presented with neck pain and stiffness and magnetic resonance imaging showed an extradural mass extending from C2 through the C4 level with moderate to severe compression of the cord. A left unilateral C2-C4 laminectomy was performed revealing an extradural rubbery tumor; a small biopsy was obtained. Examination of stained tissue revealed the presence of a parasitic worm that was identified as a gravid female Onchocerca lupi. A magnetic resonance imaging at 7 weeks follow-up showed a significantly decreased size of the enhancing lesion and the patient's symptoms gradually resolved. This is the first report of zoonotic O. lupi in the United States. The parasite has been reported in dogs and cats in the western United States, and from people in four cases reported from Europe. A great deal more needs to be learned, including full host range and geographic distribution, before we fully understand O. lupi infections in animals and man.

Endoventricular transplantation of allogenic skeletal myoblasts in a porcine model of myocardial infarction.

PURPOSE: To assess the technical feasibility of percutaneous endoventricular injection of skeletal myoblasts into an infarcted porcine myocardium. METHODS: A skeletal muscle biopsy was obtained from a donor pig and processed for myoblast expansion in vitro. Myocardial infarction was induced in a host pig via fibrin coil placement in the left anterior descending artery. Four weeks later, electromechanical mapping of the left ventricle identified the infarction site, into which approximately 200 million allogenic cells obtained from the muscle biopsy were directly injected (0.1 mL/injection at 25 sites) from inside the ventricular cavity via a needle injection catheter inserted through the femoral artery. Ten days after transplantation, the injected heart was evaluated histologically for the presence of myoblasts. RESULTS: Electrocardiography, echocardiography, left ventricular angiography, and electromechanical mapping confirmed the myocardial infarction. During the cell transfer procedure, premature ventricular contractions confirmed needle placement in the endocardium. Histological evaluation of the host heart 10 days after cell transfer revealed living myoblasts and multinucleated myotubes in the infarcted region, indicating successful transplantation. CONCLUSIONS: Direct myoblast transplantation into infarcted porcine myocardium using an endoventricular injection was technically feasible. The results in this model show that transplanted myoblasts were able to survive for 10 days after transplantation.