Gastric Nodule Turned Rare Gastric Xanthoma.

Gastric nodules (polyps) are a common finding in routine endoscopic procedures. Uncommonly, gastric nodules turn out to be lipid-filled waxy lesions called xanthomas. In this case report, we discuss a rare incidence of a gastric nodule turning out to be a xanthoma in a 50-year-old male patient. Xanthomas of the GI tract occur by the exact mechanism as their cutaneous counterpart and are relatively uncommon. A 50-year-old male with a past medical history of gastroesophageal reflux disease (GERD), hyperlipidemia, and constipation presented to our hospital with a chief complaint of epigastric discomfort, bloating, and gastric reflux, all starting the night before admission. Gastroenterology was consulted, and they performed an esophagogastroduodenoscopy (EGD) during the admission due to the patient's age and long history of GERD. EGD showed mild gastritis and xanthelasma. The patient's upper GI symptoms improved. All other workups were negative. Right upper quadrant (RUQ) US performed showed hepatic steatosis. With lifestyle changes, the patient's alkaline phosphatase returned to normal. After a month of medical management, GERD symptoms reoccurred. Repeat EGD was performed, and xanthomatous aggregates were shown, suggesting xanthoma. Upper GI symptoms continued. Gastric xanthomas are a rare occurrence. Most xanthomas in the upper GI tract are located in the stomach and have various causes. The risk for malignancy is low; these lesions are commonly confused for malignancies, prompting biopsy and histology. Overall, xanthomas are rare findings with a sinister look but benign results.

Bacteremia Secondary to Epiploic Appendagitis (EA).

Epiploic appendages are fat-filled sacs that are generally located along the surface of the large intestine. In most cases, epiploic appendagitis (EA) is described as an ischemic infarction of an epiploic appendage as the result of torsion or spontaneous thrombosis of the central draining vein of the epiploic appendage. The patient described in this report presented with a sudden onset of diffuse abdominal pain, nausea, and fever. CT scan of the abdomen and pelvis with oral contrast revealed EA of the sigmoid colon. Along the course of the admission, the patient became septic with blood cultures growing E. coli. In this case, we present a rare presentation of E. coli sepsis in the setting of EA, a usually uncomplicated and self-resolving presentation of abdominal pain.

COVID-19 Exposure Unmasking Systemic Amyloidosis With Hepatic Predominance.

Amyloidosis is characterized by depositing insoluble fibrillar proteins that misfold into beta-pleated sheets. This phenomenon occurs on a systemic or local level and may interfere with the function of various organs, including the heart, kidneys, and liver. Among those presenting with amyloidosis, hepatic, gastrointestinal, renal, cardiac, vitreous, and immunological involvement may occur. These manifestations are linked to several clinical presentations, varying from abdominal pain and hepatomegaly to restrictive cardiomyopathy and chronic renal failure. The two most common types of amyloid proteins are amyloid light chain (AL) and serum amyloid A (AA) proteins. AL produced by immunoglobulin light chains kappa and lambda (κ, λ) circulate systemically and accumulate in organs. At the same time, serum AA proteins are acute-phase reactants seen in infectious, chronic inflammatory states. In an immune-mediated infection such as COVID-19, serum AA levels may be a predictive factor of disease severity and a valuable biomarker to monitor the clinical course of COVID-19 patients. This report highlights a case in which infection with COVID-19 provoked an effective immune response that may have contributed to the accelerated progression of systemic amyloidosis with hepatic involvement. The study further investigates the involvement of AL and AA proteins in COVID-19 infections, including their role in synergistically exacerbating an already grueling clinical course.

Undifferentiated Hepatic Sarcoma: A Rare Case.

Primary hepatic undifferentiated pleomorphic sarcoma (UPS) is a rare malignant mesenchymal tumor with a nonspecific clinical and radiologic presentation. Primary hepatic UPS is often a diagnosis of exclusion made by multiple immunohistological testing that rules out hepatic, hematologic, neural, and epithelial origin. Stains for mesenchymal origin are usually the only positive stain and do not demonstrate evidence of specific mesenchymal cell differentiation. We report a case of a 56-year-old male with no significant past medical history that presented with complaint of epigastric abdominal pain of six months duration. A computed tomography (CT) scan of the abdomen and pelvis exhibited numerous hepatic masses involving right and left hepatic lobe. A CT-guided core needle biopsy discovered undifferentiated/pleomorphic sarcoma. Histomorphology showed spindle cell neoplasm without recognizable hepatic tissue. Immunohistochemistry (IHC) stains were positive for smooth muscle actin (SMA) but failed to establish a more specific histogenesis. Furthermore, IHC stains revealed spindle neoplastic cells with focal and patchy positive h-caldesmon (approximately 10-15% of neoplastic cells), and negative for desmin. Given these results, the diagnosis of undifferentiated/pleomorphic sarcoma was established. It is imperative to consider UPS in the differential diagnosis of large liver lesions without evidence of differentiation. Early identification of this rare tumor can prevent the possibility of distant metastasis and improve survival among patients.

A Rare Case of Diffuse Nodular Lymphoid Hyperplasia With Rectal Involvement.

Nodular lymphoid hyperplasia (NLH) is characterized by the growth of multiple discrete small submucosal nodules specifically confined to the lamina propria and superficial submucosa layers of the intestinal wall. Gastric and rectal involvement of NLH is exceedingly rare. To date, few case reports have described diffuse NLH presenting with multiple submucosal lymphomatous polyposis occurring in the rectum.  Our patient is a 39-year-old morbidly obese Hispanic female who presented to the gastroenterology clinic complaining of intermittent hematochezia for the past six months. Colonoscopy showed diffuse nodularity in the sigmoid colon and rectal mucosa, extending 20 cm from the rectal verge. Rectal biopsies revealed moderate active chronic inflammation predominantly of lymphoplasmacytic cells with areas of lymphoid hyperplasia and focal surface ulceration. Immunohistochemistry stains revealed reactive lymphoid hyperplasia (RLH).  The NLH is a risk factor for extraintestinal and intestinal lymphomas. When encountering lymphoid hyperplasias, the possibility of malignancy must always be considered. It is crucial to monitor patients with NLH via capsule endoscopies, small bowel series, and colonoscopy for surveillance of new lesions in light of the potential for malignancy.

A Comprehensive Analysis of the Impact of Acute Myocardial Infarction in Patients With Celiac Disease.

Background and Aims: We aimed to study the impact of acute myocardial infarction (AMI) in patients with celiac disease (CD). Methods: We used the National Inpatient Sample 2011-2018 to identify patients aged 18 years and older with a history of CD who presented with AMI using International Classification of Disease Nineth and Tenth Revision codes. Primary outcome of interest was mortality differences in AMI patients with and without CD. Secondary outcomes were in-hospital length of stay, hospital costs, and coronary revascularization. Results: A total of 2,287,840 weighted patients were included in this study with a principal diagnosis of AMI. Among this population, 183,027 weighted patients had a history of CD (0.08%), and 2,286,010 weighted patients had AMI without a history of CD (99.92%). Most AMI patients with and without CD were older (69.57 ± 13.21 vs 67.08 ± 13.87 years, respectively) and white (92.55% vs 75.39%, respectively). Patients with AMI and CD were more likely to be female than patients without CD (53.76% vs 38.47%; P < .05). In our study, we found that the difference in hospital charges (adjusted mean difference $2644.7) was lower among AMI and CD; however, length of stay was higher among patients with CD (adjusted mean difference 0.36 day) although they were not statistically significant (P > .05). Both cohorts had higher number of Medicare recipients and lower number of patients who self-pay. Our study also found that smoking was more prevalent among patients with CD, 12.14%, vs patients without CD, 2.51%. Moreover, patients with CD who developed AMI had a lower adjusted odds of mortality than those without CD (adjusted odds ratio [aOR] 0.41; P < .05). Patients with CD and AMI also had lower odds of coronary revascularization (aOR 0.80; P < .05). In addition, we found that adults with CD had a lower odds of developing AMI (aOR 0.78; P < .05). Conclusion: CD is a chronic disease leading to chronic inflammation and various nutrition-related problems which can lead to increased morbid conditions. However, we found lower odds of AMI among patients with CD, as well as lower mortality and comorbidities related to AMI, thus contradicting previous assumptions.

"To Fix a Broken Heart": An Unusual Case of Infective Endocarditis Involving the Mitral Valve With Perforation and Hemodynamic Instability.

Infective endocarditis (IE), commonly caused by Staphylococcus aureus, can affect multiple cardiac structures and lead to significant morbidity and mortality. We present a case of IE with extensive mitral valve involvement causing perforation and hemodynamic compromise. A 66-year-old Caucasian female presented to the emergency department for progressive altered mental status and lethargy. The patient and family denied history of intravenous drug use (IVDU) on interview. Physical exam revealed tachypnea, tachycardia, lethargy, and fluctuance in the right antecubital fossa draining serous fluid. Initial studies revealed a urinary tract infection, patchy bilateral opacities on chest x-ray, hypoxic respiratory failure, elevated lactate and cardiac markers, leukocytosis, and positive urine toxicology for opioid and benzodiazepine. She was intubated and admitted to the ICU, and later developed acute respiratory distress syndrome with requirement for vasopressors. Antibiotics were started, and blood cultures ultimately grew methicillin-sensitive S. aureus. Coronavirus disease 2019 (COVID-19) results were negative. Cardiology was consulted for elevated cardiac markers that were due to myocardial injury in the setting of septic shock. A transthoracic echocardiogram showed a large mobile mass on the anterior mitral leaflet. Further evaluation with transesophageal echocardiogram revealed a large, mobile, and centrally necrotic vegetation on the medial portion of the mitral annulus extending to both the anterior and posterior leaflets. Doppler of the valve showed holosystolic retrograde ejection into the left atrium confirming a perforation. The patient was transferred urgently to a cardiothoracic surgery capable center for operative intervention on the mitral valve. IE is most commonly caused by S. aureus and seen in highest rates among patients with a prosthetic valve, congenital heart disease, and intracardiac device. However, roughly 50% of IE occurs in patients without any valvular disease. Other risk factors include IVDU, valvular disease, and prior history of endocarditis. Clinical diagnosis of IE is made using the Duke's criteria, with echocardiogram and bacteremia playing a major role. The initial management involves empiric antibiotics until a pathogen is identified. Surgical consult is also suggested, and indications for surgery include heart failure due to valve dysfunction, uncontrolled infection, prevention of embolism, and hemodynamic compromise. Prompt recognition and intervention is crucial in the prevention of mortality in patients with IE leading to mitral perforation and hemodynamic compromise.

Fulminant Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis After 10 Years of Hydralazine Use.

Vasculitis, by definition, causes changes in the walls of blood vessels, including thickening, weakening, narrowing, and scarring, leading to inflammation and necrosis of the blood vessel walls. Small-vessel vasculitis is commonly associated with anti-neutrophil cytoplasmic antibodies (ANCA), which activate cytokine-primed neutrophils and monocytes that express ANCA antigens proteinase 3 (PR3) and myeloperoxidase (MPO) on their surface. The continuous injury and inflammation of these small vessels characterized by circulating immune complexes and antinuclear antibodies result in clinical features standard in all types of vasculitis. When a 59-year-old male with a history of heart failure, hypertension (on hydralazine 100 mg every eight hours for more than ten years), diabetes mellitus, and dyslipidemia presented to the hospital, he was complaining of hematuria, intermittent periumbilical abdominal pain, and 40-lb weight loss over four months. Initial evaluation showed symptomatic anemia and large blood cells with proteinuria on urine analysis. During his clinical course, the patient developed a new diffuse purpuric rash. Imaging showed systemic involvement with ground-glass opacities, diffuse alveolar hemorrhage, and peripancreatic inflammatory changes, consistent with small-vessel vasculitis. Immunological tests confirmed ANCA-associated vasculitis, and kidney biopsy showed ANCA-mediated pauci-immune glomerulonephritis supported by the salvage technique used by pronase immunofluorescence, which provides evidence against the glomerular disease of the complex immune type in the setting of MPO-ANCA seropositivity. Despite the withdrawal of hydralazine and prompt initiation of immunosuppressive therapy and alternating sessions of plasmapheresis, the patient succumbed to acute massive pulmonary hemorrhage and subsequent demise. We recommend that patients on the common antihypertensive, hydralazine, should be monitored with non-specific inflammatory markers and, if warranted, with qualitative and quantitative assessment tools to measure inflammatory disease activity for possible complications of hydralazine drug-induced vasculitis or hydralazine ANCA-associated vasculitis (HAAV). Furthermore, cumulative dosages may be a predisposing factor for HAAV to present as a pulmonary-renal syndrome, which can be fulminant and fatal, despite aggressive efforts. Therefore, screening, revisiting therapy, early diagnosis, and prompt discontinuation of the drug are imperative.

Leiomyoma in the Transverse Colon With Resection.

Benign proliferations of smooth muscle cells are known as leiomyomas; these proliferations can occur in the colon and are typically found incidentally. Colonic leiomyomas are very rare and are most commonly found in the descending or sigmoid colon. A 59-year-old Hispanic female presented to the gastroenterology clinic for surveillance colonoscopy. The biopsy showed a submucosal microscopic leiomyoma in the transverse colon. The treatment of choice for most colonic leiomyomas is surgical excision. This rare case favors the notion that endoscopic polypectomy may be superior to surgical excision, ultimately providing a less-invasive and less-costly procedure without complications or recurrence.