Rare Manifestation of a Rare Disease, Acute Liver Failure in Adult Onset Still's Disease: Dramatic Response to Methylprednisolone Pulse Therapy-A Case Report and Review.

Adult onset Still's disease (AOSD) is a rare systemic inflammatory disorder of unknown etiology. It is characterized by daily fevers, arthralgias or arthritis, typical skin rash, and leukocytosis. Hepatic involvement is frequently observed in the course of AOSD with mildly elevated transaminases and/or hepatomegaly. Fulminant hepatic failure, occasionally requiring urgent liver transplantation, is a rare manifestation of AOSD. Here, we present a case of 22-year-old woman with no significant medical history who initially came with fever, arthralgias, myalgias, generalized weakness, and sore throat. Laboratory data showed mildly elevated transaminases and markedly elevated ferritin levels. She was diagnosed with AOSD based on Yamaguchi diagnostic criteria and was started on prednisone. Three months later, while she was on tapering dose of steroid, she presented with fever, abdominal pain, jaundice, and markedly elevated transaminases. Extensive workup excluded all potential causes of liver failure. She was diagnosed with AOSD associated acute liver failure (ALF). Intravenous (IV) methylprednisolone pulse therapy was started, with dramatic improvement in liver function. Our case demonstrated that ALF can present as a complication of AOSD and IV mega dose pulse methylprednisolone therapy can be employed as a first-line treatment in AOSD associated ALF with favorable outcome.

A novel use of early radiation therapy in the treatment of hyperbilirubinemia in a patient with primary hepatic lymphoma and chronic hepatitis C.

Lymphomas arising in the liver are extremely rare. Here, we describe a case of Hepatitis C virus infection with primary hepatic lymphoma (PHL) presenting with hyperbilirubinemia. A 45-year-old African American male presented with abdominal pain, pruritus, and itching for two days. CT of abdomen and pelvis with contrast showed numerous masses in the liver. The liver biopsy was consistent with diffuse large B cell lymphoma (DLBCL). Conventional chemotherapy was avoided initially because of hyperbilirubinemia. Hence, radiation therapy was given initially to reduce his bilirubin levels and tumor size. The patient was able to complete six cycles of rituximab combined with cyclophosphamide, adriamycin, vincristine, and prednisone (R-CHOP) chemotherapy and achieved a complete response verified by positron emission tomography-computed tomography (PET-CT). PHL should be considered when there are numerous space occupying liver lesions seen on imaging. Hyperbilirubinemia may be a reason for delay in treatment for some of these patients. Hence, the role of radiation therapy prior to treatment with R-CHOP is an alternative to management for stage IV diffuse large B cell lymphoma.

Colorectal cancer disparities: issues, controversies and solutions.

Colorectal cancer (CRC) is the second leading cause of cancer related deaths in the United States. There are significant differences in CRC incidence and mortality by race with the highest burden occurring among blacks. The underlying factors contributing to CRC disparities are multiple and complex. Studies have suggested that a higher prevalence of putative risk factors for CRC, limited access to healthcare services, lower utilization of healthcare resources and increased biological susceptibilities contribute to this disparity by race. This article reviews the factors associated with the disproportionally higher burden of CRC among blacks; addresses the controversies regarding the age to begin CRC screening and the screening modality to use for blacks; and proffers solutions to eliminate CRC disparity by race.

Angiolipoma: rare cause of adult ileoileal intussusception.

Intussusception in adults is rare and more common in the paediatric population. Clinically, most adult patients have chronic non-specific symptoms due to partial obstruction. In contrast, most paediatric patients present with the classic triad of abdominal pain, vomiting and blood in stool. Adult intussusception is commonly associated with an organic aetiology, most likely a benign or malignant neoplasm as a lead point of intussusception. We describe a case of a 29-year-old woman with subacute presentation due to ileoileal intussusception secondary to a polypoid submucosal angiolipoma. Angiolipoma is a benign lesion composed of mature adipose tissue and thin-walled capillaries. The presence of thin-walled vessels differentiates it from a lipoma. Angiolipomas of the small intestine are extremely rare with very few reported cases. This case not only demonstrates an unusual benign lesion as a cause of intussusception, but also illustrates an atypical clinical presentation in adults with intussusception.