Pseudodiverticulosis: a rare presentation of eosinophilic esophagitis.

Esophageal pseudodiverticulosis is a rare endoscopic finding in eosinophilic esophagitis. We report a case of a 32-year-old male who presented with dysphagia and gastroesophageal reflux disease and was found to have esophageal pseudodiveritcula along with esophageal rings. The patient was subsequently treated with endoscopic balloon dilation and a diagnosis of eosinophilic esophagitis (EoE) with pseudodiverticulosis was made based upon the endoscopic and biopsy findings. This case provides evidence of the unusual finding of pseudodiverticulosis associated with EoE and further understanding of its pathogenesis is required.

Vanishing bile duct syndrome arising in a patient with HIV infection sequentially treated with trimethoprim/sulfamethoxazole and dapsone.

Trimethoprim/sulfamethoxazole is well known to cause intra-hepatic cholestasis which in rare instances can be prolonged and lead to vanishing bile duct syndrome. The risk regarding the potential for cross-reactivity between structurally related molecules such as dapsone and trimethoprim/sulfamethoxazole in causing hepatotoxicity is scarce. Herein, we report a case of vanishing bile duct syndrome following dapsone use in a patient with HIV infection and a recent history of trimethoprim/sulfamethoxazole-induced cholestasis. The patient had severe and protracted cholestasis during 2 years of follow-up and eventually died of liver failure.

Delayed Diagnosis of Buried Bumper Syndrome When Only the Jejunostomy Extension is Used in a Percutaneous Endoscopic Gastrostomy-jejunostomy Levodopa-carbidopa Intestinal Gel Delivery System.

Direct intrajejunal levodopa-carbidopa intestinal gel (LCIG) administered through a percutaneous endoscopic gastrostomy (PEG) with a jejunal extension tube (PEG-J) is an FDA-approved modality for treatment of patients with advanced Parkinson's disease (PD). Buried bumper syndrome (BBS) is a rare complication associated with PEG tubes inserted for drug administration or enteral feeding. The syndrome is diagnosed endoscopically revealing burial of the internal bumper in the gastric wall, causing numerous serious complications. When only the J extension of a PEG-J is used to deliver medications, and the G tube is not utilized, a delay in the diagnosis of BBS can occur. This is likely as the small caliber J extension tube remains patent and functional. We present the case of an elderly patient with advanced PD on LCIG therapy, who presented with a dislodged J-tube from a PEG-J system. Endoscopy revealed BBS that had likely developed prior to dislodgment of J-extension and despite a conservative approach, the internal bumper needed to be surgically extracted to prevent further complications.

Esophageal arteriovenous malformation, a rare cause of significant upper gastrointestinal bleeding: Case report and review of literature.

Gastrointestinal (GI) arteriovenous malformations (AVMs) are a well-known source of bleeding with colon being the most common site, but they can also occur in rare locations like the esophagus which may present with life threatening bleeding. We report the case of a 51-year-old male with end stage renal disease (ESRD) presenting with hematemesis and acute on chronic anemia. Further investigation showed an esophageal AVM which is an unusual location and it was successfully treated with an endoscopic clip instead of argon plasma coagulation (APC) due to its challenging location and esophageal wall motion from breathing. The patient continued to be asymptomatic without any upper and lower GI bleeding during his 20 months follow up period after the endoscopic management. Review of literature showed only 10 cases of AVMs involving esophagus and the average age of presentation was 52 years with a male predominance. We also provide an overview of those cases in the discussion section below.

A case of acute liver failure due to carfilzomib in multiple myeloma.

WHAT IS KNOWN AND STUDY OBJECTIVE: Carfilzomib is a newer drug approved for the treatment of relapsing and refractory multiple myeloma. It has been rarely associated with acute liver failure (ALF). CASE SUMMARY: We present a case of 58-year-old man presenting with abnormal liver function tests and subsequently diagnosed with ALF due to carfilzomib. Liver enzymes improved significantly after discontinuation of the drug. WHAT IS NEW AND CONCLUSION: Even though ALF due to carfilzomib has been documented rarely in clinical studies, no detailed case report has been published so far. Patients on carfilzomib should be monitored for ALF, and prompt discontinuation of drug is necessary in such cases.

Acute Gastrointestinal Bleeding Due to Cytomegalovirus Colitis in a Patient with Common Variable Immunodeficiency.

Common variable immunodeficiency (CVID) is a heterogeneous disorder with decreased production of immunoglobulins that presents with recurrent and serious infections in ∼90% of cases. Review of the literature showed only 12 cases of gastrointestinal infection of cytomegalovirus in patients with CVID. We present an unusual case of a CVID patient presenting with new-onset hematochezia. With proper clinical suspicion and endoscopic evaluation, cytomegalovirus colitis was diagnosed and acute bleeding was successfully treated endoscopically.

Overestimate of Fibrosis by FIBROSpect® II in African Americans Complicates the Management of their Chronic Hepatitis C.

BACKGROUND: Evaluation of advanced fibrosis in patients with hepatitis C virus (HCV) infection is used to facilitate decisions on treatment strategy and to initiate additional screening measures. Unfortunately, most studies have predominately Caucasian (Cau) patients and may not be as relevant for African Americans (AA). AIMS: This study specifically addresses the issue of defining minimal vs. significant fibrosis in African Americans (AA) with chronic hepatitis C (CHC) using noninvasive assays. METHODS: All patients (n = 319) seen between 1 January 2008 and 30 June 2013 for whom a FibroSpect II® (FSII) assay was performed and had data for calculation of aspartate aminotransferase (AST) platelet ratio index (APRI) and Fibrosis-4 (FIB-4) were identified using the medical records. RESULTS: When liver biopsy score and FSII assay results for the AA patients with CHC were compared, 31% of AA had advanced FSII fibrosis scores (F2-F4) despite a biopsy score of F0-F1. In contrast, 10% of Cau over-scored. The AA false positive rate was 14% for APRI and 34% for FIB-4. Combining FSII with either APRI (7% false positive) or FIB-4 (10% false positive) improved the false positive rate in AA to 7% (FSII + APRI) and 10% (FSII + FIB-4) but reduced the sensitivity for significant fibrosis. CONCLUSIONS: The FSII assay overestimates fibrosis in AA and should be used with caution since these patients may not have significant fibrosis. If the APRI or FIB-4 assay is combined with the FSII assay, minimal fibrosis in AA can be defined without subjecting the patients to a subsequent biopsy.

Retroperitoneal amyloidosis as the presenting manifestation of Waldenstrom's macroglobulinaemia.

Retroperitoneal amyloidosis has been described in a few case reports and is typically a secondary manifestation of inflammation or malignancy. We present the case of a 69-year-old man who presented with a large pleural effusion and an incidental retroperitoneal mass in the CT imaging. Further investigation confirmed the diagnosis of amyloid amyloidosis involving the retroperitoneum as well as a concurrent Waldenstrom's macroglobulinaemia. Chemotherapy consistent of drugs active against both the lymphoid and plasma cell components of the disease is the proposed therapy for Waldenstrom's macroglobulinaemia in those patients amenable to receive chemotherapy and can make a difference in the survival.