A Curious Case of Gastrointestinal Eosinophilia Induced by Treatment With Immune Checkpoint Inhibitors.

Immune checkpoint inhibitors have revolutionized oncologic treatment. However, they are linked to various side effects,1 a rare one being gastrointestinal eosinophilia. We present a patient with malignant melanoma treated with nivolumab. She underwent upper endoscopy 6 months later which showed a duodenal ulcer and linear furrows of her esophagus. Biopsies of the esophagus, stomach, and duodenum were consistent with eosinophilic infiltration. Repeat endoscopy after nivolumab discontinuation revealed near-complete resolution of eosinophilia in the stomach and duodenum, with lingering eosinophilia in the esophagus. The purpose of this report was to increase awareness of gastrointestinal eosinophilia associated with checkpoint inhibitors.

An unusual and challenging cause of small bowel bleeding: Isolated gastrointestinal blue rubber bleb nevus syndrome.

Blue rubber bleb nevus syndrome (BRBNS) is a rare disease that presents as cutaneous and extra-cutaneous vascular malformations, most commonly affecting the gastrointestinal (GI) tract. We report a case of adult onset BRBNS in an African American male with vascular lesions isolated to the jejunum without any cutaneous manifestations. Physicians should recognize that BRBNS can present without skin involvement and may have complications from visceral organ involvement. Treatment of BRBNS is mainly symptomatic and aims at preserving the GI tract as much as possible. BRBNS may also present as delayed recurrence after surgical or endoscopic interventions.

Accuracy of Noninvasive Fibrosis Scoring Systems in African American and White Patients With Nonalcoholic Fatty Liver Disease.

OBJECTIVES: Nonalcoholic fatty liver disease fibrosis score (NFS), fibrosis-4 (FIB-4) score, aspartate aminotransferase (AST)-to-platelet ratio index (APRI) score, and AST-alanine aminotransferase (ALT) ratio are noninvasive fibrosis scoring systems for the staging of liver fibrosis in patients with chronic liver disease. METHODS: In a large cohort of patients with nonalcoholic fatty liver disease, we compared AST-ALT ratio, NFS, FIB-4 score, and APRI score in predicting advanced fibrosis (defined as fibrosis stage ≥ 3) in histologically confirmed African American (AA) and white patients. We identified 907 patients: 677 (74.6%) white and 230 (25.3%) AA patients with nonalcoholic fatty liver disease. RESULTS: Of the 907 patients, 115 (12.8%) patients had advanced fibrosis (stages 3 and 4) in the total cohort: 6 (2.6%) AAs, and 109 (16.2%) whites. In AAs, the area under the receiver operating characteristic (area under the curve) for predicting advanced fibrosis was 0.58 by NFS, 0.86 by APRI score, 0.77 by FIB-4 score, and 0.65 by AST-ALT ratio. In whites, the area under the receiver operating characteristic for predicting advanced fibrosis was 0.82 by NFS, 0.82 by APRI score, 0.88 by FIB-4 score, and 0.76 by AST-ALT ratio. In the AA population, NFS > 0.675, FIB-4 score > 2.67, and APRI score > 1.5 each has a negative predictive value of 98%, whereas the negative predictive values in whites are 91%, 88%, and 85%, respectively. DISCUSSION: Noninvasive fibrosis scoring systems can reliably exclude advanced fibrosis in both AAs and whites and have acceptable discriminatory ability to predict advanced fibrosis in whites. The utility of noninvasive fibrosis scoring systems in predicting advanced fibrosis in AAs needs further validation in a larger multicenter cohort.

Challenges in Management of Autoimmune Hepatitis With Concurrent Graves Thyrotoxicosis.

The management of concurrent Graves thyrotoxicosis and autoimmune hepatitis (AIH) can be challenging. We present a 37-year-old woman with a recent diagnosis of Graves disease and acute liver injury. Laboratory workup was concerning for AIH. Liver biopsy showed plasma cell infiltration and interface hepatitis consistent with AIH, and treatment with methylprednisolone was initiated. Azathioprine was started after thiopurine methyltransferase testing, and prednisone was tapered down. Thionamide use was contraindicated, so clinical euthyroidism was achieved with the use of cholestyramine and glucocorticoids. Our case highlights the complexities of management when patients are affected by 2 concurrent illnesses.