Severe Ulcerative Colitis as a Complication of Mild COVID-19 Infection in a Vaccinated Patient.

Prior studies have proposed a direct correlation between the severity of coronavirus disease 2019 (COVID-19) and the severity of ulcerative colitis (UC). This is explained by an autoimmune response from molecular mimicry or via angiotensin-converting enzyme 2 receptor. However, we present a novel case of an inverse correlation between asymptomatic COVID-19 causing severe UC. An 84-year-old male with prior infectious colitis and asymptomatic COVID-19 presented with septic shock secondary to presumed infectious colitis. Blood workup suggested inflammatory bowel disease, which was confirmed to be UC via flexible sigmoidoscopy and pathology. He was managed successfully with oral mesalamine and high-dose intravenous steroids, which were later transitioned to an oral taper. This case reflects that the intensity of the impact of COVID-19 on the gastrointestinal system can be as variable as the immune system reaction in an already labile environment such as in the elderly and malnourished patients. Therefore, in view of a lack of reports establishing a relationship between these two entities, we aim to report a case and propose an association between mild or asymptomatic COVID-19 and severe UC.

A Unique Case of Invasive Adenocarcinoma of the Body and Tail of the Pancreas Presenting as Gastric Outlet Obstruction.

Advanced-stage pancreatic cancer can present as secondary gastric outlet obstruction (GOO), which is an extremely rare entity. Given the initial vague presentation of gastrointestinal symptoms, the diagnosis is often delayed, leading to high morbidity and mortality. We report the case of a 68-year-old male patient who presented with vomiting, epigastric pain, and weight loss. CT abdomen and pelvis showed a distended stomach with a transition point in the duodenum. Immediate stomach decompression through the nasogastric tube was performed. Upper endoscopy (EGD) revealed ischemic gastritis with gastric body necrosis. Biopsy of the duodenum revealed moderately differentiated invasive adenocarcinoma. Magnetic resonance cholangiopancreatography (MRCP) showed a 7-cm mass centered in the body and the tail of the pancreas, invading the duodenojejunal junction. No surgical or oncological management was indicated due to the advanced stage of the malignancy at the time of the diagnosis. Malignant GOO, even though rare, should be a part of the differential diagnosis in elderly patients with vague gastrointestinal symptoms.

Recurrence with malignancy after endoscopic resection of large colon polyps with high-grade dysplasia: incidence and risk factors.

BACKGROUND: In the West, piecemeal endoscopic resection remains the primary treatment for large colon polyps (LCP), as most recurrences are believed to be benign and resectable with follow-up endoscopy. However, invasive malignancy at the site of prior piecemeal endoscopic mucosal resection has been reported in the Asian literature. This study aims to identify the incidence of and the risk factors for local recurrence with malignancy after endoscopic resection of LCP with high-grade dysplasia (HGD). METHODS: In this retrospective cohort study, we identified patients undergoing complete endoscopic resection of LCPs (≥ 20 mm) with HGD at the Cleveland Clinic between January 2000 and December 2016. Demographic, endoscopic, and pathologic data were collected. All subsequent endoscopic and pathology reports were reviewed to identify recurrence. The cumulative incidence of malignancy at the polypectomy site was determined and univariate analysis was performed to assess risk factors. RESULTS: A total of 254 LCPs with HGD were resected in 229 patients. Mean polyp size was 29.2 mm. There were 138 lesions resected in piecemeal fashion and 116 en-bloc. After a median follow-up of 28.7 months for the entire cohort, local recurrence with malignancy was diagnosed in six cases. Median time to malignancy diagnosis was 28.5 months. All malignant cases occurred after piecemeal resection and none after en-bloc resection (HR 11.4; 95% CI 0.48-273). CONCLUSION: Malignancy after endoscopic resection of LCPs with HGD is uncommon and may be associated with piecemeal resection. When possible, en-bloc resection should be the goal for the management of LCPs.

A Case of Spontaneous Pneumothorax 21 Days After Diagnosis of Coronavirus Disease 2019 (COVID-19) Pneumonia.

BACKGROUND At the end of 2019, coronavirus (SARS-CoV-2) was recognized as the cause of a cluster of pneumonia cases in Wuhan, a city in China. There are numerous complications associated with COVID-19 infection, such as acute respiratory distress syndrome, renal failure, circulatory shock, and multi-organ failure. Spontaneous pneumothorax following COVID-19 pneumonia is an extremely rare complication. CASE REPORT We report the case of a 49-year-old man with a past medical history of type 2 diabetes mellitus with an initial presentation of cough, shortness of breath, and fever. He was diagnosed with COVID-19 pneumonia and rapidly deteriorated on the day of admission, requiring initiation of mechanical ventilation. The patient recovered clinically and was discharged home. He returned 21 days after discharge with a spontaneous pneumothorax. CONCLUSIONS Spontaneous pneumothorax is a rare complication after apparent recovery from COVID-19 pneumonia. It is imperative that treating physicians are aware of this complication in order to recognize it early and treat it promptly.

Prevalence and Predictors of Gastrointestinal Dysmotility in Patients with Hypermobile Ehlers-Danlos Syndrome: A Tertiary Care Center Experience.

Introduction Ehlers-Danlos syndrome (EDS), specifically the hypermobility type (hEDS), is associated with a variety of gastrointestinal (GI) conditions. This study aims to evaluate the prevalence of and factors associated with gut dysmotility in patients with hEDS. Methods This is a retrospective study of hEDS patients conducted at the Cleveland Clinic's Center for Personalized Genetic Healthcare between January 2007 and December 2017. Demographics, GI motility testing, endoscopic, and imaging data were extracted from the patients' charts. Results A total of 218 patients with hEDS were identified. Among them, 136 (62.3%) patients had at least one GI symptom at the time of EDS diagnosis. Motility testing was performed and reported in 42 (19.2%) patients. Out of them, five (11.9%) had esophageal dysmotility, 18 (42.8%) had gastroparesis, five (11.9%) had small bowel/colon altered transit time, and four (9.5%) had global dysmotility. In univariable analysis, patients with postural orthostatic tachycardia syndrome (POTS) [odds ratio (OR): 8.88, 95% CI: 3.69-24.9, p<0.0001], fibromyalgia (OR: 4.43, 95% CI: 2.04-10.1, p=0.0002), history of irritable bowel syndrome (OR: 5.01, 95% CI: 2.31-11.2, p<0.0001), and gastroesophageal reflux disease (OR: 3.33, 95% CI: 1.55-7.44, p=0.002) were more likely to be diagnosed with GI dysmotility. On multivariable analysis, only POTS (OR: 5.74, 95% CI: 2.25-16.7, p=0.0005) was significantly associated with an increased likelihood of GI dysmotility. Conclusions This study suggests that GI symptoms are relatively common among patients with hEDS. Of the patients tested for dysmotility, 76.2% were found to have some form of dysmotility. POTS was found to be an independent predictive factor for GI dysmotility.

Hemophagocytic syndrome masquerading as septic shock: An approach to such dilemma.

INTRODUCTION: Hemophagocytic syndrome or hemophagocytic lymphohistiocytosis is a rare condition characterized by excessive inflammation that is thought to be caused by the absence of normal downregulation of activated macrophages and lymphocytes. The treatment of hemophagocytic lymphohistiocytosis can depend on whether it is primary or secondary. In secondary hemophagocytic lymphohistiocytosis, the treatment can be directed according to the cause. In general, protocol HLH-94 (which consists of dexamethasone and etoposide in induction and maintenance) has been widely used as it has good outcomes. Hemophagocytic lymphohistiocytosis and septic shock largely overlap which can lead to refractory septic shock and death if not treated. Unfortunately, there is no clear approach for such dilemma. Thereby, we would like to present our case as it has a valuable approach to hemophagocytic lymphohistiocytosis in the setting of sepsis. CASE DESCRIPTION: A 60-year-old female, with history of hypertension, came with fever, productive cough, and dyspnea; she was admitted for acute exacerbation of chronic obstructive pulmonary disease and was transferred to intensive care unit for septic shock. The patient progressed to refractory septic shock with no focus of infection. After further investigations, detailed history raised the suspicion of hemophagocytic lymphohistiocytosis; a bone marrow biopsy was collected and confirmed the diagnosis. The patient was on methylprednisolone while waiting for other investigation results and improved markedly. After ruling out secondary causes of hemophagocytic lymphohistiocytosis, she was switched to protocol-94 and continued to improve. CONCLUSION: It should be emphasized that septic shock, with or without focus of infection, overlaps with hemophagocytic lymphohistiocytosis and can consequently lead to refractory septic shock and death. Thus, our aim of this case is to encourage further investigations, specifically for hemophagocytic lymphohistiocytosis in the setting of septic shock of unknown origin, to decrease mortality rate. More importantly, early initiation of immunosuppression therapy may be a crucial step before switching to hemophagocytic lymphohistiocytosis-specific treatment.