A Rare Cause of Upper Gastrointestinal Bleeding: Sarcina ventriculi.

We describe a patient who presented with hematemesis and was found to have unusually well-demarcated erythematous mucosa with a 2-3 cm irregular nonbleeding necrotic ulcer in the gastric body on esophagogastroduodenoscopy. Biopsy and pathologic examination of the tissue indicated infection with a rare bacterium, Sarcina ventriculi, prompting treatment with an unproven combination of 4 agents: metronidazole, ciprofloxacin, sucralfate, and pantoprazole. Repeat esophagogastroduodenoscopy 8 weeks later revealed complete resolution of the ulceration and surrounding erythema. These results may contribute toward establishing an appropriate therapeutic regimen for future S. ventriculi infections.

Extracellular matrix dysfunction in Sorsby patient-derived retinal pigment epithelium.

Sorsby Fundus Dystrophy (SFD) is a rare form of macular degeneration that is clinically similar to age-related macular degeneration (AMD), and a histologic hallmark of SFD is a thick layer of extracellular deposits beneath the retinal pigment epithelium (RPE). Previous studies of SFD patient-induced pluripotent stem cell (iPSC) derived RPE differ as to whether these cultures recapitulate this key clinical feature by forming increased drusenoid deposits. The primary purpose of this study is to examine whether SFD patient-derived iPSC-RPE form basal deposits similar to what is found in affected family member SFD globes and to determine whether SFD iPSC RPE may be more oxidatively stressed. We performed a careful comparison of iPSC RPE from three control individuals, multiple iPSC clones from two SFD patients' iPSC RPE, and post-mortem eyes of affected SFD family members. We also examined the effect of CRISPR-Cas9 gene correction of the S204C TIMP3 mutation on RPE phenotype. Finally, targeted metabolomics with liquid chromatography and mass spectrometry analysis and stable isotope-labeled metabolite analysis were performed to determine whether SFD RPE are more oxidatively stressed. We found that SFD iPSC-RPE formed significantly more sub-RPE deposits (∼6-90 µm in height) compared to control RPE at 8 weeks. These deposits were similar in composition to the thick layer of sub-RPE deposits found in SFD family member globes by immunofluorescence staining and TEM imaging. S204C TIMP3 correction by CRISPR-Cas9 gene editing in SFD iPSC RPE cells resulted in significantly reduced basal laminar and sub-RPE calcium deposits. We detected a ∼18-fold increase in TIMP3 accumulation in the extracellular matrix (ECM) of SFD RPE, and targeted metabolomics showed that intracellular 4-hydroxyproline, a major breakdown product of collagen, is significantly elevated in SFD RPE, suggesting increased ECM turnover. Finally, SFD RPE cells have decreased intracellular reduced glutathione and were found to be more vulnerable to oxidative stress. Our findings suggest that elements of SFD pathology can be demonstrated in culture which may lead to insights into disease mechanisms.

Three-vessel fenestrated and bilateral iliac branched graft repair of a juxtarenal aortic aneurysm with bilateral common iliac aneurysms.

We describe a patient with large bilateral common iliac artery aneurysms as well as a large juxtarenal abdominal aortic aneurysm successfully treated by a novel approach. The procedure, completed in one setting, involved this sequence: positioning and deployment of bilateral iliac branch grafts with appropriate internal iliac limbs; insertion of a three-vessel fenestrated proximal device with cannulation and stenting of the left renal artery; and positioning and deployment of a bifurcated endograft and two mating limbs to the bilateral iliac branch device. The procedure was completed with percutaneous access; the patient recovered well and was discharged on postoperative day 1.