Liver Cirrhosis Secondary to Autoimmune Hepatitis in a Patient with Alpha-1 Antitrypsin ZZ Phenotype: A "Double Hit" Phenomenon.

Alpha-1 antitrypsin deficiency has been known to cause pulmonary and hepatic diseases. Cirrhosis in patients with alpha-1 antitrypsin deficiency, especially in a homozygotes ZZ phenotype, has been described to occur exclusively as a congenital disease. We present the case of a young 28-year-old female who was initially followed for thrombocytopenia and was found to have cirrhosis of the liver with autoimmune histological features suggesting the possibility that another "second hit" can contribute to a more rapid progression of liver disease.

An Early Presentation of Buried Bumper Syndrome.

Percutaneous endoscopic gastrostomy (PEG) is a well-established and successful method of nutritional delivery. Complications, although rare, are divided into early or late. Buried bumper syndrome (BBS) is usually a late complication of PEG tube insertion and can cause many issues such as pressure necrosis, peritonitis, and septic shock. Endoscopic evaluation is the definitive diagnosis, and treatment depends on each patient and the degree of depth of disc migration. We present to you a case of buried bumper syndrome in a 66-year-old female that was initially thought to be complicated with peritonitis, and surprisingly occurring only one week after initial PEG tube placement.

Percutaneous Mechanical Pulmonary Thrombectomy in a Patient With Pulmonary Embolism as a First Presentation of COVID-19.

There has been a high incidence of thromboembolic diseases in patients with coronavirus disease 2019 (COVID-19) pneumonia. We present a case of a healthy 32-year-old male with no past medical history who presented with shortness of breath, tested positive for COVID-19, and was found to have a large acute saddle pulmonary embolism.

A Rare Case of Pancreatic Tuberculosis Diagnosed via Endoscopic Ultrasound-Guided Fine Needle Aspiration and Polymerase Chain Reaction.

Pancreatic tuberculosis (TB) is a very rare condition even in endemic areas of the world where the disease is considered to be highly prevalent. The presenting features are usually vague and its radiological features mimic pancreatitis and pancreatic malignancy. We present a case of a 26-year-old active military male, originally from Virginia with no past medical history who presented to the ED with a two-week history of abdominal pain, increased nausea and vomiting, decreased appetite, increased darkening of his urine, and pale-colored stools. His physical examination was remarkable for conjunctival icterus as well as generalized abdominal tenderness. His laboratory results were remarkable for a total bilirubin of 4.7 mg/dL, direct bilirubin of 3.9 mg/dL, and alkaline phosphatase of 583 U/L. A CT scan was performed showing an intrahepatic dilatation and abrupt obstruction of the common bile duct at the level of a mass. Subsequent MRI of the abdomen was performed which showed a pancreatic mass at the uncinate process obstructing the common bile duct and causing intrahepatic bile dilation. The patient was deemed a surgical candidate and endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic ultrasound (EUS) was performed for the sake of staging and showed a biliary compression in the middle of the common bile duct for which a stent was placed, and fine-needle aspiration (FNA) of the pancreatic mass was performed which was consistent with necrotizing granulomatous lymphadenitis. After further diagnostic studies, the patient was diagnosed with pancreatic TB. This case highlights the unusual presentation of extrapulmonary TB as well as the importance of EUS-guided FNA in diagnosing pancreatic TB which was presumed to be a malignant mass and candidate for unnecessary surgical resection.