The rope sign, a typical and yet infrequent clue.

Cutaneous granulomatous reactions are diverse, both from the clinical and the pathological perspective. Most underlying pathophysiological aspects remain elusive. Interstitial granulomatous dermatitis and palisaded neutrophilic and granulomatous dermatitis have been claimed to be reactions to systemic disorders, such as infectious, inflammatory, or neoplastic conditions. Recently, the overarching term "reactive granulomatous dermatitis" has been coined to unify both entities. We herein report two cases of reactive granulomatous dermatitis presenting with the widely known, albeit infrequent "rope sign" and provide clinicopathological correlation. The two patients included a 53-year-old woman with enlarging erythematous plaques and underlying palpable cords on both sides of trunk near axillae (rope sign), and a 51-year-old woman with personal history of rheumatoid arthritis and a palpable cord on the left aspect of the trunk. Pathological findings were compatible with reactive granulomatous dermatitis in both cases. In conclusion, the rope sign represents a strikingly infrequent but decisive diagnostic clue of reactive granulomatous dermatitis.

Monkeypox outbreak in Spain: clinical and epidemiological findings in a prospective cross-sectional study of 185 cases.

BACKGROUND: Since May 2022, a new outbreak of monkeypox has been reported in several countries, including Spain. The clinical and epidemiological characteristics of the cases in this outbreak may differ from those in earlier reports. OBJECTIVES: To document the clinical and epidemiological characteristics of cases of monkeypox in the current outbreak. METHODS: We conducted a prospective cross-sectional study in multiple medical facilities in Spain to describe the cases of monkeypox in the 2022 outbreak. RESULTS: In total, 185 patients were included. Most cases started with primarily localized homogeneous papules, not pustules, in the probable area of inoculation, which could be cutaneous or mucous, including single lesions. Generalized small pustules appeared later in some of them. Heterogeneous lesions occurred during this generalized phase. All patients had systemic symptoms. Less common lesions included mucosal ulcers (including pharyngeal ulcers and proctitis) and monkeypox whitlows. Four patients were hospitalized, none died. Smallpox vaccination and well-controlled HIV disease were not associated with markers of severity. Contact during sex is the most likely mechanism of transmission. In this outbreak, cases have been described in men who have sex with men and are strongly associated with high-risk sexual behaviours. Seventy-six per cent of the patients had other sexually transmitted diseases upon screening. CONCLUSIONS: The clinical findings in this outbreak differ from previous findings and highly suggest contact transmission and initiation at the entry site. The characterization of the epidemiology of this outbreak has implications for control. What is already known about this topic? Monkeypox eruption is described as consisting of pustules. The roles of HIV and previous smallpox vaccination in the prognosis are unknown. The transmission route was initially described as respiratory droplets and was later suggested to be via sexual contact. What does this study add? Initial lesions at the probable inoculation area were homogeneous and papular (pseudopustules). Generalized small pustules appeared later in some of them. Heterogeneous lesions occurred during this generalized phase. All patients had systemic symptoms. Less common signs included mucosal ulcers (including pharyngeal ulcers and proctitis) and monkeypox whitlows. Well-controlled HIV and previous smallpox vaccination were not associated with severity. No patient died. The data support the hypothesis of transmission via contact during sex. Although this might change, the outbreak is currently limited mostly to men who have sex with men, with high-risk factors for sexually transmitted diseases.

Endoscopy for the diagnosis and treatment of gastrointestinal bleeding caused by malignancy.

BACKGROUND AND AIM: The diagnosis and treatment of gastrointestinal (GI) bleeding secondary to malignancy can be challenging. Endoscopy is the gold standard to diagnose and treat gastrointestinal bleeding but clinical characteristics and outcomes of patients with malignancy-related bleeding are not well understood. This study aims to look at clinical characteristics, endoscopic findings, safety and clinical outcomes of endoscopic interventions for GI malignancy-related bleeding. METHODS: We retrospectively reviewed outcomes of patients with confirmed GI malignancies who underwent endoscopy for GI bleeding at MD Anderson Cancer Center between 2010 and 2019. Cox hazard analysis was conducted to identify factors associated with survival. RESULTS: A total of 313 patients were included, with median age of 59 years; 74.8% were male. The stomach (30.0%) was the most common tumor location. Active bleeding was evident endoscopically in 47.3% of patients. Most patients (77.3%) did not receive endoscopic treatment. Of the patients who received endoscopic treatment, 57.7% had hemostasis. No endoscopy-related adverse events were recorded. Endoscopic treatment was associated with hemostasis (P < 0.001), but not decreased recurrent bleeding or mortality. Absence of active bleeding on endoscopy, stable hemodynamic status at presentation, lower cancer stage, and surgical intervention were associated with improved survival. CONCLUSIONS: This study indicates that endoscopy is a safe diagnostic tool in this patient population; while endoscopic treatments may help achieve hemostasis, it may not decrease the risk of recurrent bleeding or improve survival.

Clinical Characteristics and Outcomes of Oral Mucositis Associated With Immune Checkpoint Inhibitors in Patients With Cancer.

BACKGROUND: Immune checkpoint inhibitor (ICI) therapy predisposes patients to immune-related adverse events (irAEs). Data are limited regarding the incidence, management, and outcomes of one such irAE: mucositis. In this study, we evaluated the clinical characteristics, disease course, treatment, and outcomes of ICI-mediated mucositis. METHODS: This was a retrospective, single-center study of patients who received ICI therapy and developed oral mucositis at The University of Texas MD Anderson Cancer Center from January 2009 to September 2019. Inclusion criteria included age ≥18 years, a diagnosis of oral mucositis and/or stomatitis based on ICD-9 and ICD-10 codes, and therapy using CTLA-4 or PD-1/L1 inhibitors alone or combined with other agents. RESULTS: We identified 152 patients with a mean age of 60 years, 51% of whom were men. Of the sample patients, 73% had stage IV cancer, with melanoma the most common (28%). Median time from ICI initiation to mucositis was 91 days. The most common clinical presentation of mucositis was odynophagia and/or oral pain (89%), 91% developed CTCAE grade 1-2 mucositis, and 78% received anti-PD-1/L1 monotherapy. Compared with anti-PD-1/L1-based therapy, anti-CTLA-4-based therapy was more frequently associated with earlier onset of mucositis (73 vs 96 days; P=.077) and a lower rate of symptom resolution (76% vs 92%; P=.029); 24% of patients required immunosuppressive therapy, which was associated with longer symptom duration (84 vs 34 days; P=.002) and higher mucositis recurrence rate (61% vs 32%; P=.006). ICI interruption was associated with worse survival (P=.037). Mucositis recurrence, immunosuppressant use, and presence of other irAEs did not affect survival. CONCLUSIONS: For ICI-mediated mucositis, a diagnosis of exclusion has not been well recognized and is understudied. Although the clinical symptoms of mucositis are mostly mild, approximately 25% of patients require immunosuppression. Mucositis recurrence can occur in approximately 39% patients. Our results showed that ICI interruption compromises overall survival.

Pilomatrixoma of the Forearm in an Elderly Male.

Pilomatrixoma or pilomatricoma is a benign adnexal neoplasm originating from the hair matrix, the inner sheath of the hair follicle, and the hair cortex. Although it is considered rare in adults, numerous cases have been documented in the literature. We present a case of an elderly male who sought consultation due to a newly appearing nodular lesion on his left forearm. Several benign and malignant entities were included in the original differential diagnosis. High-frequency ultrasonographic features suggested a cystic neoplasm with calcification and mild intralesional vascularity. Ultimately, histopathological examination confirmed the diagnosis of pilomatricoma. In this study, our aim is to review the importance of the available diagnostic tools, such as dermoscopy, and the emerging utility of cutaneous high-frequency ultrasonography. Some rarer pathological variants are also discussed, including perforating, anetodermic, bullous and pigmented pilomatricoma. We hope that exposure to these clinical, dermoscopic, ultrasonographic, and histopathological images will encourage clinicians to consider pilomatricoma in their differential diagnosis when approaching nodular lesions, regardless of location and patient's age.

Characteristics and Outcomes of Cancer Patients With Venous Thromboembolic Events After Treatment With Immune Checkpoint Inhibitors.

OBJECTIVE: This study aimed to describe the clinical characteristics and outcomes of patients with venous thromboembolism (VTE) after Immune checkpoint inhibitors (ICI), focusing on patients with gastrointestinal (GI) immune-related adverse events (irAE). METHODS: In this retrospective, single-center study, we report the clinical outcomes of adult cancer patients who developed a VTE within 2 years of ICI initiation. Patients were excluded if alternate causes of VTE were present apart from malignancy and cancer therapy. The cohort was classified into those with GI-irAE, non-GI-irAE, and no irAE. A control group with ICI exposure without irAE and VTE was selected for comparative analysis. RESULTS: Of all ICI-treated patients, 1891 (17.2%) were diagnosed with VTE. In all, 501 (4.6%) had no etiology for VTE aside from malignancy and cancer therapy. Of these, 137 patients were included and classified as: 44 GI-irAE, 42 non-GI-irAE, and 51 no irAE. Chemotherapy within 6 months of ICI therapy was associated with increased VTE risk. There was no difference in the clinical course between those exposed to chemotherapy versus ICI therapy alone, time from ICI initiation to VTE, and VTE type, recurrence, or related hospitalization. While there was no difference in VTE-related mortality, the GI-irAE group was associated with lower all-cause mortality and superior overall survival. CONCLUSION: Combined ICI and chemotherapy use increased VTE risk. There is a similar disease course of VTE after ICI exposure, regardless of other irAEs. Co-existing GI-irAE with VTE is associated with superior overall survival. Prospective studies are needed to evaluate the relationship between ICI therapy and VTE and irAE impact on VTE outcomes.

The Quick Sepsis-Related Organ Failure Assessment Score Is Prognostic of Pancreatitis Severity in Patients With Alcohol-Induced Pancreatitis.

OBJECTIVES: The aim of this study was to determine if the quick Sepsis-Related Organ Failure Assessment (qSOFA) score assessed at and 48 hours after admission is prognostic for alcohol-induced acute pancreatitis (AAP) severity. METHODS: This is a retrospective cohort review study of 161 patients admitted to a single academic hospital in Houston, TX, with the diagnosis of AAP. Receiver operator characteristics analysis and logistic regression were used to assess the diagnostic accuracy and prognostic ability of the qSOFA score. RESULTS: A qSOFA score of 2 or higher at and 48 hours after admission had a specificity of 94% or greater and sensitivity of 33% or higher for pancreatitis severity and need for intensive care admission, intubation, or vasopressors. The qSOFA score at and 48 hours after admission was prognostic of intensive care unit admission by an adjusted odds ratio of 48.5 (95% confidence interval [CI], 6.4-1013.3; P < 0.001) and 18.8 (95% CI, 2.2-467.3; P < 0.05), respectively. The qSOFA score at admission was prognostic of severe pancreatitis by an adjusted odds ratio of 35.3 (95% CI, 7.2-224.3; P < 0.001). CONCLUSIONS: A qSOFA score of 2 or higher is highly specific and prognostic of multiple clinical outcomes both at and 48 hours after admission in patients with AAP.

Hypophosphatemia Is More Common and Is Prognostic of Poorer Outcomes in Severe Alcoholic Pancreatitis.

OBJECTIVES: The aim of this study was to determine if hypophosphatemia is more common in patients with severe alcohol-induced acute pancreatitis (AAP). METHODS: This is a retrospective, single institution, cohort study that analyzed 147 patients admitted to the hospital for AAP. Multivariate logistic regression was used to determine if hypophosphatemia would be related to clinical outcomes of disease severity. RESULTS: Hypophosphatemia was more common in patients with severe AAP at admission; in addition, all patients with severe AAP (100%) eventually developed hypophosphatemia during admission, relative to those with mild (43%) and moderately severe (54%) AAP. The magnitude of the lowest phosphate measurement obtained during admission was lower in patients with severe AAP (mean, 1.5 mg/dL, standard deviation [SD], 0.5 mg/dL) relative to those with mild (mean, 2.6 mg/dL; SD, 0.9 mg/dL) and moderately severe (mean, 2.3 mg/dL; SD, 0.9 mg/dL) AAP (P < 0.001). Finally, patients who developed hypophosphatemia during admission were more likely to require intensive care unit admission (P < 0.001), vasopressors (P = 0.01), or intubation (P = 0.003). CONCLUSIONS: Hypophosphatemia is more common and of greater magnitude in patients admitted to the hospital with severe AAP. In addition, patients with severe AAP who develop hypophosphatemia during admission are more likely to have poorer clinical outcomes.

Elevated transaminases and hypoalbuminemia in Covid-19 are prognostic factors for disease severity.

Prognostic markers are needed to understand the disease course and severity in patients with Covid-19. There is evidence that Covid-19 causes gastrointestinal symptoms and abnormalities in liver enzymes. We aimed to determine if hepatobiliary laboratory data could predict disease severity in patients with Covid-19. In this retrospective, single institution, cohort study that analyzed patients admitted to a community academic hospital with the diagnosis of Covid-19, we found that elevations of Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT) and Alkaline Phosphatase (AP) at any time during hospital admission increased the odds of ICU admission by 5.12 (95% CI: 1.55-16.89; p = 0.007), 4.71 (95% CI: 1.51-14.69; p = 0.01) and 4.12 (95% CI: 1.21-14.06, p = 0.02), respectively. Hypoalbuminemia found at the time of admission to the hospital was associated with increased mortality (p = 0.02), hypotension (p = 0.03), and need for vasopressors (p = 0.02), intubation (p = 0.01) and hemodialysis (p = 0.002). Additionally, there was evidence of liver injury: AST was significantly elevated above baseline in patients admitted to the ICU (54.2 ± 15.70 U/L) relative to those who were not (9.2 ± 4.89 U/L; p = 0.01). Taken together, this study found that hypoalbuminemia and abnormalities in hepatobiliary laboratory data may be prognostic factors for disease severity in patients admitted to the hospital with Covid-19.

Esophageal necrosis associated with sodium polystyrene sulfonate (Kayexalate) use.

Acute esophageal necrosis is a rare cause of gastrointestinal bleeding. Endoscopically, it appears as a circumferential black-appearing mucosa affecting almost universally the mid and distal esophagus. Risk factors include low flow states, malnutrition, alcoholism, and the presence of multiple comorbidities. Prolonged exposure to gastric secretions and direct contact with corrosive agents also induce mucosal ischemia. Sodium polystyrene sulfonate use has been associated with severe gastrointestinal adverse events, including increased risk of small bowel and colonic necrosis and perforation. In susceptible individuals, sodium polystyrene sulfonate can also induce esophageal ischemia and necrosis, as illustrated in this case.

Spontaneous splenic rupture associated with Escherichia coli bacteremia and dual antiplatelet therapy.

Splenic rupture is a life-threatening condition that usually occurs after blunt abdominal trauma. It can lead to hemorrhagic shock and death if not diagnosed quickly. Rarely, spontaneous rupture of the spleen may occur without a history of trauma. In these cases, establishing a diagnosis is challenging due to the ambiguous presentation of the conditions associated with it. Infections and hematological malignancies are the two most common causes of spontaneous splenic rupture. Here, we report a case of spontaneous splenic rupture in the setting of Gram-negative bacteremia and recent initiation of dual antiplatelet therapy.

The Model for End-Stage Liver Disease-Sodium Score at Admission Is Prognostic of Covid-19 Disease Severity.

Covid-19 is a systemic viral respiratory illness that can cause gastrointestinal manifestations. There is evidence that Covid-19 can infect liver tissue and may cause transaminemia. A prognostic model is needed to aid clinicians in determining disease severity. The Model for End-Stage Liver Disease-Sodium (MELD-Na) score is a mortality assessment tool in liver transplant patients that has been found to be prognostic in other clinical situations. This study aimed to determine if the MELD-Na score was associated with disease severity in patients with Covid-19, as assessed by multiple clinical outcomes including death within 30 days of discharge and development of an acute kidney injury (AKI). This is a retrospective cohort study that analyzed patients admitted to a community academic hospital with the diagnosis of Covid-19. The 30-day MELD-Na score was found to be significantly higher in those who died (14.38 ± 6.92) relative to those who survived (9.68 ± 5.69; p = 0.03). Additionally, patients with a MELD-Na score greater than 10 were found to have higher risk of developing an AKI (odds ratio (OR) 3.31 (1.08, 10.17); p = 0.03), need for hemodialysis (OR 9.69 (1.74, 53.96); p = 0.007), require vasopressors (OR 4.55 (1.22, 16.99); p = 0.02), and have a longer hospital stay (OR 4.17 (1.05, 16.47); p = 0.03). The MELD-Na score may serve as a useful clinical scoring system for prognosis in patients admitted to the hospital with Covid-19.

Elevated D-Dimer Is Associated with Multiple Clinical Outcomes in Hospitalized Covid-19 Patients: a Retrospective Cohort Study.

D-dimer is a prognostic marker for Covid-19 disease mortality and severity in hospitalized patients; however, little is known about the association between D-dimer and other clinical outcomes. The aim of this paper was to define a threshold of D-dimer to use in hospitalized patients with Covid-19 and to assess its utility in prognosticating in-hospital mortality, development of an acute kidney injury (AKI), and need for hemodialysis, vasopressors, or intubation. This is a single-center, retrospective, cohort review study of 100 predominantly minority patients (94%) hospitalized with Covid-19. The electronic medical record system was used to collect data. Receiver operating characteristics (ROC) and area under the curve (AUC) analysis were used to determine optimal thresholds of peak D-dimer, defined as the highest D-dimer obtained during admission that was clinically meaningful. Odds ratios were then used to assess the relationship between peak D-dimer thresholds and clinical outcomes. D-dimer > 2.1 µg/mL and > 2.48 µg/mL had > 90% sensitivity and > 50% specificity for predicting need for vasopressors (AUC 0.80) or intubation (AUC 0.83) and in-hospital mortality (AUC 0.89), respectively. Additionally, D-dimer > 4.86 µg/mL had a 100% sensitivity and 81% specificity for predicting the need for hemodialysis (AUC 0.92). Furthermore, peak D-dimer > 2.48 µg/mL was associated with in-hospital mortality (p < 0.001), development of an AKI (p = 0.002), and need for intubation (p < 0.001), hemodialysis (p < 0.001), and vasopressors (p < 0.001). Peak D-dimer > 2.48 µg/mL may be a useful threshold that is prognostic of multiple clinical outcomes in hospitalized patients with Covid-19.

A Rare Case of Pancreatitis-Induced Thrombosis of the Aorta and Superior Mesenteric Artery.

It is estimated that there are more than 210,000 hospital admissions for acute pancreatitis and more than 56,000 admissions for chronic pancreatitis each year in the United States. Pancreatitis comes with numerous complications that can increase morbidity, mortality, and length of hospital stay. Local and systemic complications include pseudocysts, necrosis, sepsis, multiorgan failure, and vascular complications. Thrombosis of the splanchnic venous system occurs in approximately 2% of patients with pancreatitis, but thrombosis is rarely seen in the arterial system. In this report, we describe a case of thrombosis of the abdominal aorta and superior mesenteric artery in a female patient who presented with acute pancreatitis.