Cytomegalovirus duodenitis associated with life-threatening duodenal hemorrhage in an immunocompetent patient: A case report.

INTRODUCTION: Cytomegalovirus (CMV) is known to be opportunistic in immunocompromised patients. However, there have been emerging cases of severe CMV infections found in immunocompetent patients. Gastrointestinal (GI) CMV disease is the most common manifestation affecting immunocompetent patients, with duodenal involvement being exceedingly rare. Presented is a case of an immunocompetent patient with life-threatening bleeding caused by CMV duodenitis, requiring surgical intervention. PRESENTATION OF CASE: A 60-year-old male with history of disseminated Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia and aortic valve infective endocarditis, presented with life-threatening upper GI hemorrhage. Endoscopy revealed ulcerations, with associated generalized mucosal bleeding in the duodenum. After repeated endoscopic therapies and failed interventional-radiology arterial embolization, the patient required a duodenectomy and associated total pancreatectomy, to control the duodenal hemorrhage. Pathologic review of the surgical specimen demonstrated CMV duodenitis. Systemic ganciclovir was utilized postoperatively. DISCUSSION: GI CMV infections should be on the differential diagnosis of immunocompetent patients presenting with uncontrollable GI bleeding, especially in critically ill patients due to transiently suppressed immunity. Endoscopic and histopathological examinations are often required for diagnosis. Ganciclovir is first-line treatment. Surgical intervention may be considered if there is recurrent bleeding and CMV duodenitis is suspected because of high potential for bleeding-associated mortality. CONCLUSION: Presented is a rare case of life-threatening GI hemorrhage caused by CMV duodenitis in an immunocompetent patient. The patient failed endoscopic and interventional-radiology treatment options, and ultimately stabilized after surgical intervention.

Time of infliximab therapy initiation and dose escalation in Crohn's disease.

AIM: To determine if early initiation of anti-tumor necrosis factor therapy affects the need for dose escalation. METHODS: This was a retrospective review of patients receiving infliximab therapy for Crohn's disease (CD) at two outpatient gastroenterology clinics during July 2009 to October 2010. All patients included in the study were biologic agent naïve and had moderate to severe CD (Harvey Bradshaw index > 8). Patients were divided into groups based on length of time between diagnosis to therapy initiation and concurrent immunosuppressant therapy. Kaplan-Meier survival analysis was used to compare the time to dose escalation for the four groups. RESULTS: There were 68 patients, 51% female and 49% male, with an average age at diagnosis of 24.7 ± 11.9 years. The average age at infliximab initiation was 34.8 ± 14.8 years. Of the 68 patients, 19% initiated inflixiamb within 2 years of diagnosis, and 51% had concurrent immunosuppressant therapy at the time of therapy initiation. Fifty percent of patients required dose escalation and the median time from therapy initiation to dose escalation was 10 mo (interquartile range: 5.3-14.8). There was a statistically significant higher probability of requiring dose esclataion in patients who initiated biologic therapy within 2 years of diagnosis, without concurrent immunosuppressant therapy (P < 0.01). CONCLUSION: Those who receive infliximab within 2 years of CD diagnosis require more intense immunosuppressant therapy than those who received infliximab later.

Outcome of cervical intraepithelial neoplasia 2 diagnosed by punch biopsy in 131 women.

AIM: To study the outcome of biopsy-diagnosed cervical intraepithelial neoplasia (CIN) 2 in patients treated by loop electrosurgical excision procedure (LEEP) or cold knife cone biopsy (CKC). MATERIAL AND METHODS: Patients (n = 131) were analyzed for histological results on LEEP/CKC specimen. Demographic and risk factors, referral cytology, high risk human papilloma virus (HR HPV) test and follow-up colposcopic clinic visits were studied. RESULTS: Excisional specimens from LEEP/CKC demonstrated no CIN in 20 (15%), CIN 1 in 17 (13%), CIN 2 in 57 (44%) and CIN 3 in 37 (28%). No invasive cancers were identified. The referral Pap smear was high grade or possible high grade in 52 (40%), low grade in 59 (45%) and inconclusive in 20 (15%). Fourteen patients (11%) had positive excisional margins, eight of the 14 were tested for HR HPV infection before LEEP, and all were positive. Post-treatment HPV testing was performed at the 12-month visit in 6 of the 14 patients who had positive excision margins, and all 6 tested were negative. Two women (1.5%) with clear margins had recurrence of CIN 2, both tested positive for HR HPV after treatment. CONCLUSION: Our data showed that a significant number of women (28%) with biopsy-diagnosed CIN 2 had CIN 1 or no dysplasia on subsequent excisional biopsy. The recurrence risk of high grade dysplasia in CIN 2 is low (1.5%). However, due to the high number of patients (72%) with high grade dysplasia at treatment biopsy, caution needs to be exercised when a conservative approach is adopted in the management of CIN 2.

Patient satisfaction with inpatient care provided by the Sydney Gynecological Oncology Group.

PURPOSE: Patient satisfaction with the provision of hospital oncology services can have a significant impact on their overall treatment experience. AIMS: To assess patient satisfaction with the inpatient hospital services in the gynecological oncology setting using the IN-PATSAT32 questionnaire developed by the European Organization for Research and Treatment of Cancer (EORTC). METHODS: A modified version of the IN-PATSAT32 questionnaire with additional 16 items was administered to 52 adult surgical inpatients admitted with the Sydney Gynecological Oncology Group. All participants were provided with an information leaflet regarding the survey and written consent obtained. RESULTS: A high response rate (100%) from patients with varied social, ethnic, and educational backgrounds confirmed the acceptability of the survey. Standard of medical care provided, frequency of doctors' visits, exchange of information with doctors, friendliness of the staff, and state of the room ranked highly (>95%) on the patient satisfaction scales. Problems were identified with ease of access to and within the hospital, quality of food, and exchange of information with other hospital staff. CONCLUSIONS: Overall the satisfaction with inpatient care was rated very highly in most areas. Deficiencies in certain elements of provision of medical care to the patients were identified and steps have been taken to improve upon these shortcomings.

Virilization in pregnancy due to a borderline mucinous ovarian tumor.

Virilization in pregnancy due to borderline mucinous ovarian tumors is very rare. A case of a 28-year-old patient who was noted at 28 weeks' gestation to have marked virilization with raised serum androgens, ascites and a large complex right adnexal mass is presented. Delivery was carried out by cesarean section and at surgery a large tumor was noted in the right ovary. Histology revealed a borderline mucinous ovarian tumor with stromal luteinization, but there was no evidence of stromal invasion. Serum androgens returned to normal levels following surgery and the maternal virilization had resolved at the 6-week postnatal visit. Stromal changes in borderline mucinous ovarian tumors may result in virilization due to androgen production; surgical removal is associated with an excellent clinical outcome.

Intravenous proton pump inhibitors before endoscopy in bleeding peptic ulcer with high-risk stigmata: a multicentre comparative study.

BACKGROUND: It is not clear if starting intravenous proton pump inhibitors (IV PPI) before endoscopic therapy provides additional benefit over starting it afterward in patients with high-risk ulcer stigmata of peptic ulcer disease. METHODS: All patients who received IV pantoprazole bolus and infusion and underwent endoscopy in six Canadian hospitals over 20 months were reviewed. Only patients with high-risk ulcer stigmata (arterial bleeding, oozing, nonbleeding visible vessel or adherent clot) were included. Patients receiving IV PPI before endoscopy (before group) were compared with those who received it after endoscopy (after group) with respect to endoscopic findings and, secondarily, to patient demographics and clinical outcomes. RESULTS: The demographics and baseline characteristics of the before group (n=57) and the after group (n=109) were similar. The before group was more likely to have had IV PPI started outside of daytime hours, and median time to endoscopy in patients admitted with upper gastrointestinal bleeding was 24 h (interquartile range 9.5 to 35) in the before group and 11.3 h (interquartile range 3.7 to 17.2) in the after group (P<0.0001). At the time of endoscopy, 33% of patients in the before group had actively bleeding lesions (Forrest 1a or 1b) compared with 54% in the after group (P=0.01), but there were no significant differences in rebleeding, surgical rates, intensive care unit admission or death between the groups. CONCLUSION: IV PPI infusions before endoscopy may lower the proportion of actively bleeding peptic ulcer lesions at endoscopy, but this finding does not appear to affect rates of rebleeding, surgery or death.

Description of prescribing practices in patients with upper gastrointestinal bleeding receiving intravenous proton pump inhibitors: a multicentre evaluation.

BACKGROUND: Intravenous forms of proton pump inhibitors (IV PPI) are routinely used for patients with acute upper gastrointestinal bleeding, but a significant concern for their inappropriate use has been suggested. patients and METHODS: All consecutive patients who received IV PPI (pantoprazole) over 20 months in six Canadian hospitals were reviewed. Prescribing practices, endoscopic findings and outcomes were recorded. RESULTS: A total of 854 patients received IV PPI. Over 90% of patients were given IV PPI for treatment of known or suspected active upper gastrointestinal bleeding. Most patients (69%) underwent upper endoscopy, and 58% of these patients had peptic ulcer disease (PUD). The majority of patients who had endoscopy (57%) had IV PPI administered in advance of the procedure. Of the 334 patients who had IV PPI given in advance, 46 (13.8%) were found to have high risk bleeding PUD stigmata at endoscopy. The remaining 288 patients (86.2%) with advance IV PPI had low-risk PUD lesions or non-PUD lesions; IV PPI was continued after endoscopy in 164 (56.9%) of these patients. CONCLUSIONS: IV PPI is often used before endoscopy in suspected upper gastrointestinal bleed and maintained, regardless of endoscopic findings, after the endoscopy in many Canadian centres. Further study is required to support these clinical practices.

Management of large bowel obstruction in advanced ovarian cancer with intraluminal stents.

BACKGROUND: While most patients with advanced ovarian cancer can achieve prolonged remission with surgery and chemotherapy, eventually most will recur. Commonly bowel obstruction will complicate their recurrence, usually heralding the terminal phase of their disease. Standard management of bowel obstruction has involved surgical intervention after a period of conservative medical management. Unfortunately, many patients submitted for surgery do not derive benefit from such an approach, spending the majority of their remaining life in the hospital or recovering from the surgery. CASES: Two cases of patients with large bowel obstruction resulting from advanced and recurrent ovarian cancer are presented. In the first case, a rectal stent was decided upon as the appropriate management as she was failing first-line therapy, with little likelihood of recovering from a laparotomy. In the second case a large recurrent infected tumor mass had already been debulked, but was continuing to cause obstructive symptoms. In both cases immediate relief of their gastrointestinal symptoms was achieved. CONCLUSIONS: In patients with large bowel obstruction secondary to extrinsic compression, useful palliation can be achieved with a colonoscopically placed endoluminal stent.