Bilateral adrenal histoplasmosis presenting as adrenal mass mimicking malignancy in an immunocompetent patient.

We report a case of a 78-year-old immunocompetent man who presented with worsening fatigue and lethargy for one month. He had also been complaining of cough and SOB for two months which had been attributed to his underlying COPD and possible pneumonia. CT showed bilateral pleural effusions, ground-glass opacities, cirrhosis, splenomegaly and bilateral adrenal masses which was highly suspicious for malignancy. After pheochromocytoma was ruled out, EUS-FNA guided biopsy was performed on the left adrenal gland. Histology was positive for yeast cells, with fungal staining (PAS) revealing narrow-based budding compatible with Histoplasma. The patient was treated with amphotericin and itraconazole. Our case is unique as he presented with hepatosplenomegaly, which is reported in less than a quarter of cases. Although typically a diagnosis in immunocompromised patients, a high index of clinical suspicion is required to diagnose disseminated histoplasmosis in an immunocompetent patient. The gold standard for diagnosis is fungal tissue culture. However results may take up to weeks. EUS-FNA guided biopsy of adrenal glands can aid in early definitive diagnosis and management.

Endoscopic Mucosal Resection for Colonic Mucosal Neoplasia and Evaluation of Long-Term Recurrence: A Single-Center Experience of 500 Cases.

OBJECTIVES: Endoscopic mucosal resection (EMR) is an alternative to surgery for the treatment of large laterally spreading lesions. Residual or recurrent adenoma is a major limitation. This study aimed to quantify early and late recurrences and to assess its associated risk factors. METHODS: The study was a single-center, multiendoscopist, longitudinal study conducted between January 1, 2013 and April 26, 2017. A total of 480 patients with 500 polyps who underwent an endoscopic resection were included. Surveillance colonoscopy (SC) was performed at 4 to 6 months (SC1) and 16 to 18 months (SC2). RESULTS: At SC1, early recurrence was noted in 77 of 354 (21.8%) lesions; 76 (98.7%) were treated endoscopically. The remaining 277 of 354 (78.2%) lesions had no recurrence at SC1; only 41 lesions (15%) were followed up at SC2. Recurrence at SC2 was found in 4 lesions (9.8%), all of which were treated endoscopically. Lesion size >40 mm was associated with recurrence. Recurrence at both SC1 and SC2 was successfully treated endoscopically in 78 of 81 lesions (96.3%). CONCLUSIONS: EMR is an effective, minimally invasive technique for the treatment of large laterally spreading lesions. Although recurrence is a concern, its risk is low (21.8% on SC1 and 9.8% on SC2) and was managed endoscopically in 96.3% cases on follow-up endoscopy.

Colon mucosal neoplasia referred for endoscopic mucosal resection: Recurrence of adenomas and prediction of submucosal invasion.

BACKGROUND: Endoscopic mucosal resection (EMR) is an effective and minimally invasive alternative to surgery for large polyps and laterally spreading lesions. Gross morphology and surface characteristics may help predict submucosal invasion of the lesion (SMIL) during endoscopic evaluation. This is one of the largest single-center studies reporting endoscopic mucosal resection for larger (≥ 20 mm) colorectal lesions in the United States. AIM: To determine the recurrence rate of adenomas and endoscopic features that may predict submucosal invasion of colonic mucosal neoplasia. METHODS: This is a retrospective cohort study of all the patients referred for endoscopic mucosal resection for lesions ≥ 20 mm, spanning a period from January 2013 to February 2017. The main outcome measure was identifying features that may predict submucosal invasion of mucosal lesions and predict recurrence of adenomas on follow-up surveillance colonoscopy performed at 4-6 mo. RESULTS: A total of 480 patients with 500 lesions were included in the study. The median age was 68 (Inter quantile range: 14) with 52% males. The most common lesion location was ascending colon (161; 32%). Paris classification 0-IIa (Flat elevation of mucosa - 316; 63.2%); Kudo Pit Pattern IIIs (192; 38%) and Granular surface morphology (260; 52%) were most prevalent. Submucosal invasion was present in 23 (4.6%) out of 500 lesions. The independent risk factors for SMIL were Kudo Pit Pattern IIIL + IV and V (Odds ratio: 4.5; P value < 0.004) and Paris classification 0-IIc (Odds ratio: 18.2; P value < 0.01). Out of 500, 354 post-endoscopic mucosal resection scars were examined at surveillance colonoscopy. Recurrence was noted in 21.8% (77 cases). CONCLUSION: There was overall low prevalence of SMIL in our study. Kudo pit pattern (IIIL + IV and V) and Paris classification 0-IIc were the only factors identified as an independent risk factor for submucosal invasion. The independent risk factor for recurrence was adenoma size (> 40 mm). Almost all recurrences (98.8%) were treated endoscopically.

Endoscopic ultrasound-guided liver biopsy using a 22-G fine needle biopsy needle: a prospective study.

BACKGROUND: Endoscopic ultrasound-guided liver biopsy (EUS-LB) using a 19-gauge (19-G) EUS needle is becoming increasingly popular. We evaluated the efficacy and safety of a 22-G EUS fine needle biopsy (FNB) needle for performing EUS-LB. METHODS: Patients referred for evaluation of elevated liver enzymes and without obstructive disease requiring endoscopic retrograde cholangiopancreatography (ERCP) were included. Using a 22-G FNB needle, two passes were made from the left lobe and one from the right. The main outcome measure was adequacy of the specimen for histology interpretation, and the secondary outcome was the safety of EUS-guided liver biopsy with a 22-G FNB needle. Patients were followed for post-procedure complications for 30 days. RESULTS: 40 patients (median age 61 years; 26 women) underwent EUS-LB. Analyzing by needle passes, the median longest core fragment was 12 mm (1st quartile - 3rd quartile 10 mm - 16.25 mm, interquartile range [IQR] 6.25 mm) from the left lobe and 11 mm (10 mm - 15.75 mm, IQR 5.75 mm) from the right lobe. The median cumulative core length per patient was 55 mm (44.5 mm - 68 mm, IQR 23.5 mm). The median cumulative number of complete portal triads (CPTs) per patient was 42 (28.5 - 53, IQR 24.5). The specimen was considered adequate in all 40 patients (100 %). Self-limiting abdominal pain was reported in 6 patients (15 %). CONCLUSIONS: EUS-LB using a 22-G FNB needle is a safe and viable alternative to the use of larger gauge needles, yielding adequate tissue for evaluation of parenchymal disease in 100 % of the patients.

Both Full Glasgow-Blatchford Score and Modified Glasgow-Blatchford Score Predict the Need for Intervention and Mortality in Patients with Acute Lower Gastrointestinal Bleeding.

BACKGROUND: Glasgow-Blatchford score (GBS) has been developed for risk stratification in management of acute upper gastrointestinal (GI) bleeding. However, the performance of GBS in patients with lower GI bleeding is unknown. AIM: To evaluate the performance of full or modified GBS and modified GBS in prediction of major clinical outcomes in patients with lower GI bleeding. METHODS: A retrospective study of patients admitted to a tertiary care center with either non-variceal upper GI bleeding or lower GI bleeding was conducted. The full and modified GBS were calculated for all patients. The primary outcome was a combined outcome of inpatient mortality, need for endoscopic, surgical, or radiologic procedure to control the bleed or treat the underlying source, and need for blood transfusion. RESULTS: A total of 1026 patients (562 cases for upper GI and 464 cases for lower GI) were included in the study. Hospital-based interventions and mortality were significantly higher in upper GI bleeding group. The performance of the full GBS in lower GI bleeding (area under the receiver operating curve (AUROC) 0.78, 95% CI 0.74-0.82) was comparable to full GBS in upper GI bleeding (AUROC 0.77, 95% CI 0.73-0.81) in predicting the primary outcome. Similarly, the performance of modified GBS in lower GI bleeding was shown to be comparable to modified GBS in upper GI bleeding (AUROC 0.78, 95% CI 0.74-0.83 vs. AUROC 0.76 95% CI 0.72-0.80). CONCLUSION: In patients with lower GI bleeding, both full GBS and modified GBS can predict the need for hospital-based interventions and mortality.

Monocular diplopia-associated migraine-like headache induced by nicotine withdrawal.

We describe an extremely rare case of migraine-associated monocular diplopia developed in a 23-year-old man after sudden cessation of smoking. The physical examination and brain MRI scan were unremarkable. The symptoms resolved after starting nicotine patch. We reviewed the literature and discussed the diagnosis and possible mechanism of this phenomenon.

Signet Cell in the Brain: A Case Report of Leptomeningeal Carcinomatosis as the Presenting Feature of Gastric Signet Cell Cancer.

Malignant infiltration of pia and arachnoid mater, referred to as leptomeningeal carcinomatosis (LMC), is a rare complication of gastric carcinoma. The most common underlying malignancy in patients with LMC are leukemia, breast cancer, lymphoma, and lung cancer. We report a case of gastric adenocarcinoma that presented with LMC in the absence of overt gastrointestinal signs or symptoms. A 56-year-old Hispanic woman presented to the hospital with a three-week history of intermittent headaches and visual blurring. An initial brain imaging showed infarction in the distribution of right posterior inferior cerebellar artery (PICA) along with communicating hydrocephalus. She underwent ventriculoperitoneal (VP) shunt placement with improvement in her symptoms. Two months later she presented again with deterioration in her mental status. Imaging studies and cerebrospinal fluid (CSF) analysis confirmed the diagnosis of LMC. Further studies determined the primary tumor to be signet ring cell gastric adenocarcinoma. However, she did not have any preceding gastrointestinal symptoms. In light of the poor prognosis, the patient's family proceeded with comfort care measures. Our case portrays a rare presentation of gastric adenocarcinoma with LMC without other distant organ metastatic involvement. It also illustrates the occult nature of gastric carcinoma and signifies the importance of neurologic assessment of patients, with or at risk of gastric carcinoma. â€‹It also raises a theoretical concern for VP shunt as a potential conduit of malignant cells from the abdomen to the central nervous system, which may serve as an important susbtrate for future research.

Predictors of the Need for Therapeutic Intervention in Older Adult Patients With a Nonvariceal Gastrointestinal Bleed.

OBJECTIVE: Gastrointestinal bleeding (GIB) is a common cause of hospitalization in the older adult population. The aim of the study was to identify factors that are associated with the need for a therapeutic intervention in patients older than 65 years with nonvariceal GIB. METHODS: This is a retrospective cohort study of older adult patients admitted to a tertiary care center between 2009 and 2011 with nonvariceal GIB. The primary outcome was a composite endpoint of inpatient mortality or need for an endoscopic, surgical, or radiologic procedure to control the bleed or to treat the underlying source of the bleed. RESULTS: A total of 314 patients were included. In-hospital mortality was 1.3% (4 patients). An intervention to control the bleeding was performed in 15 patients (4.8%). Four patients (1.3%) needed a nonurgent intervention. Twenty-three patients (7.23%) had the primary combined outcome of in-hospital mortality or need for any therapeutic endoscopic, surgical, or radiologic intervention. Factors that were independently associated with the primary outcome were systolic blood pressure within the first 24 hours of <90 mm Hg (odds ratio 3.05, 95% confidence interval 1.08-8.59, P = 0.001), and initial hemoglobin of <7 g/dL (odds ratio 4.81, 95% confidence interval 1.56-14.74, P = 0.006). CONCLUSIONS: Nonvariceal GIB in older adult patients ceases spontaneously in most patients without an invasive intervention. Systolic blood pressure within the first 24 hours of <90 mm Hg and an initial hemoglobin level of <7 g/dL could be used to identify high-risk patients who may benefit from an urgent therapeutic intervention.