The Epidemiology and Clinical Presentation of Pancreatic Divisum: A Case Series of 57 Case Reports.

OBJECTIVES: Pancreatic divisum (PD) is the second most common congenital abnormality of the pancreatic duct, which affects 2% to 3% of the population. Most of the population remains asymptomatic, but in people who present with symptoms, it can be a cause of anguish and should be recognized. The main goal of this article was to provide a comprehensive picture of clinical and epidemiological methods of diagnosis and treatment of PD. METHODS: A total of 57 PD case reports were considered in this descriptive analysis with 51 case reports and case series published within the last 25 years. The search strategies include systemic searches using scholarly search engines such as Medscape, Scopus, Cochrane, and PubMed. RESULTS: The 57 cases we studied have an average age of presentation of 42 years, with female sex (58%) predominance. Common presenting symptoms were abdominal pain (87.72%) and radiation to the back (21.6%). Eighty-one percent of the case studies reported pancreatitis, and 63.2% had recurrent pancreatitis. At presentation, laboratory values demonstrated increased amylase, lipase, and liver enzymes. PD was diagnosed using magnetic resonance cholangiopancreatography (28.1%), endoscopic retrograde cholangiopancreatography (57.9%), endoscopic ultrasound (7%), or computed tomography (5.3%) scan of the abdomen. Of significance, biliary duct dilation was found in 70.6% of patients diagnosed as having PD. Incidental masses were found in 66.7% of the patients. The most successful treatment was sphincterotomy with or without stents (47.6%), followed by pancreatoduodenectomy (19%) and pancreaticojejunostomy (10%). CONCLUSIONS: Physicians managing pancreatitis should add PD to their differential diagnoses because it will help improve patient outcomes and avoid unfavorable consequences.

Milk fat globule-epidermal growth factor 8 (MFGE8) prevents intestinal fibrosis.

OBJECTIVE: Intestinal fibrosis is considered an inevitable consequence of chronic IBD, leading to stricture formation and need for surgery. During the process of fibrogenesis, extracellular matrix (ECM) components critically regulate the function of mesenchymal cells. We characterised the composition and function of ECM in fibrostenosing Crohn's disease (CD) and control tissues. DESIGN: Decellularised full-thickness intestinal tissue platforms were tested using three different protocols, and ECM composition in different tissue phenotypes was explored by proteomics and validated by quantitative PCR (qPCR) and immunohistochemistry. Primary human intestinal myofibroblasts (HIMFs) treated with milk fat globule-epidermal growth factor 8 (MFGE8) were evaluated regarding the mechanism of their antifibrotic response, and the action of MFGE8 was tested in two experimental intestinal fibrosis models. RESULTS: We established and validated an optimal decellularisation protocol for intestinal IBD tissues. Matrisome analysis revealed elevated MFGE8 expression in CD strictured (CDs) tissue, which was confirmed at the mRNA and protein levels. Treatment with MFGE8 inhibited ECM production in normal control HIMF but not CDs HIMF. Next-generation sequencing uncovered functionally relevant integrin-mediated signalling pathways, and blockade of integrin αvß5 and focal adhesion kinase rendered HIMF non-responsive to MFGE8. MFGE8 prevented and reversed experimental intestinal fibrosis in vitro and in vivo. CONCLUSION: MFGE8 displays antifibrotic effects, and its administration may represent a future approach for prevention of IBD-induced intestinal strictures.

A Case Report of Cardiac Failure in a Patient on Teduglutide for High-Output Ileostomy Stoma.

A high volume of ileostomy output in patients with extensive bowel resection can be hard to manage. This leads to extensive loss of fluids and electrolytes along with malabsorption. Medications have traditionally controlled it by delaying intestinal transit and decreasing intestinal and gastric secretion using opiates, loperamide, diphenoxylate, omeprazole, somatostatin, and octreotide. However, many patients depend on parenteral nutrition and fluid and electrolyte infusions, even with optimal drug therapy. Despite the best possible care, they may develop renal failure. Teduglutide is a glucagon-like peptide-2 (GLP-2) analog given as a daily subcutaneous injection, and it has been promising in managing short bowel syndrome. It has been effective in decreasing the dependence on parenteral nutrition. However, improving fluid and electrolyte balance can precipitate cardiac failure in some patients, especially those with borderline cardiac functions, hypertension, and thyroid disorders. This usually presents in the first few months of the initiation of teduglutide therapy and may require stopping the medication. We present the case report of an elderly female with a high-output stoma on parenteral nutrition on teduglutide. There was a significant decrease in stoma output, and parenteral nutritional support could be stopped. However, she presented with worsening dyspnea and was diagnosed with cardiac failure with an ejection fraction of 16%-20%. The baseline ejection fraction was 45%, done six months before this. Coronary angiography showed no stenosis in any vessels, and the decline in left ventricular ejection fraction and fluid overload was attributed to teduglutide therapy.

Correction: A Case Report of Takotsubo Cardiomyopathy With Myxedema Coma.

[This corrects the article DOI: 10.7759/cureus.32652.].

Pulmonary Adenocarcinoma Mimicking Pneumonia in a Young Adult.

Lung cancer is the third most common cancer in the United States. Lung adenocarcinoma is a subtype of non-small cell lung cancer. On computed tomography (CT) it can appear as ground glass nodules, consolidative opacity, or solid mass lesions located in the periphery. Because it can appear as a consolidation, it can sometimes be confused with an infectious process such as pneumonia. We present a case of a 27-year-old male initially diagnosed with pneumonia; however, three months later, when he presented to the hospital with worsening pleuritic chest pain, fever, and dyspnea after a bronchoscopy a week before admission, pathology was positive for adenocarcinoma.

An Interesting Case of Prostate Cancer Presenting With Colonic Metastasis.

Prostate cancer is common cancer that grows slowly and tends to metastasize to bones, lungs, and the liver. Most malignancies have established patterns in presentation, localization, and organs where they metastasize. We are presenting a case of a 60-year-old man who presented with abdominal pain and, on further investigation, was found to have polyps in the colon, a flat rectal mass with eccentric thickening of the rectum, a moderately enlarged prostate, and multiple liver masses suggestive of metastasis. It was initially thought to be colorectal cancer with metastasis but was eventually diagnosed as a stage IV prostate adenocarcinoma with metastases to the liver and rectum. It is very unusual for prostate cancer to present with distal metastasis to the liver and rectum, as in this case.

Amoxicillin-Clavulanate Induced Liver Injury in a Young Female.

Amoxicillin-clavulanate (AC) is an antibiotic widely used for various infections. It has rarely been associated with drug-induced liver injury (DILI), mainly in males 55 or older with associated alcohol consumption or medications causing liver injury. Here we present an atypical case of a 22-year-old female with a past medical history of celiac disease and alopecia areata who was prescribed AC in urgent care for bilateral cervical lymphadenopathy, nausea, and chills. Her nausea and vomiting worsened after taking AC for three days, and she developed jaundice. On workup, she was found to have deranged liver functions, and pan-lobular hepatitis was confirmed on liver biopsy. She started to improve symptomatically after withdrawing AC, and her transaminases started showing a decreasing trend.

Abdominal Compartment Syndrome (ACS) With Sigmoid Volvulus (SV): Lost Hours Are Lost Lives.

Normal intra-abdominal pressure (IAP) ranges from 0 to 5, and abdominal compartment syndrome (ACS) occurs when a sustained IAP >20 mmHg causes organ dysfunction. ACS mainly occurs in patients who are critically ill. It occurs due to an injury or disease in the abdomen or pelvic area, including trauma, abdominal surgery, acute pancreatitis, pancreatic ileus, volvulus, fecal impaction, and ruptured abdominal aortic aneurysm. If not recognized early, ACS leads to multiorgan dysfunction, shock, and sepsis and has high morbidity and mortality. Our patient was brought to the emergency department (ED) following cardiac arrest and resuscitation and was diagnosed with sigmoid volvulus (SV) and ACS. SV is seen in older men, and its presentation is often insidious and leads to bowel gangrene and ACS. The patient's delay in presenting to the hospital and the severity of his condition leads to a poor outcome despite surgery. A delay in recognizing ACS can lead to a worse outcome.

A Rare Case of Acute Compartment Syndrome (ACS) Involving the Upper Limb in a Patient on Warfarin.

Acute compartment syndrome (ACS) is an acute event characterized by increased pressure in the extremities where fascia encloses muscles, vessels, and nerves, leading to complications in tissue perfusion and, eventually, tissue necrosis and death. This is usually seen after trauma, crush injuries, and fractures. Similar events can also happen in the abdomen and lead to impaired perfusion in the abdominal organs. Hypovolemia, medications, and repeated or suboptimal diagnostic tests tend to worsen a pre-existing ACS, and the mainstay of its management is fasciotomy to prevent ischemic necrosis and rhabdomyolysis. Here we discuss a 64-year-old female with ACS involving the left upper limb, secondary to anticoagulation on warfarin and aspirin for atrial fibrillation. Her history was significant for peripheral vascular disease, above-knee amputation, and congestive heart failure. This article emphasizes the importance of early recognition and management of ACS to salvage limbs.

A Case Report of Nodular Regenerative Hyperplasia and Non-cirrhotic Portal Hypertension Post Oxaliplatin Chemotherapy.

Oxaliplatin is widely used in chemotherapeutic regimens for colorectal carcinoma, its recurrence, and metastasis, and is associated with better outcomes. However, oxaliplatin use is associated with injury to hepatic sinusoidal endothelium and the development of nodular regenerative hyperplasia (NRH) in the liver, which can be differentiated from nodular hyperplasia of cirrhosis by the presence of diffuse micronodular transformation without a fibrous band and the lack of perinuclear collagen tissue. This causes non-cirrhotic portal hypertension (NCPH), which presents with splenomegaly and variceal bleeding and preserved synthetic liver function. Its treatment revolves around managing variceal bleeding with banding, sclerotherapy, and beta blockers. Some patients may end up requiring liver transplantation because of recurrent variceal bleeding. We present the case of a 46 years old female who presented with recurrent variceal bleeding due to NCPH and NRH six years after treatment of colon carcinoma with oxaliplatin.

A Young Adult With Essential Thrombocythemia Presenting as Myocardial Infarction.

Essential thrombocythemia (ET) is a myeloproliferative neoplasm involving the clonal proliferation of platelets. It is Philadelphia negative and is associated with Janus kinase 2 (JAK2), calreticulin (CALR), or myeloproliferative leukemia virus oncogene (MPL) mutations. The resultant platelets have quantitative and qualitative defects, making them more sticky and prone to thromboembolism. However, ET does not only affect platelet survival, it also has a low leukemogenic potential. It's more common in the elderly, 60 years or more, but can be seen in all age groups, including children. Patients with ET have an increased risk of vascular events like hemorrhage and thromboses like cerebrovascular events, myocardial infarction, superficial thrombophlebitis, deep vein thrombosis, and pulmonary embolism. Cardiovascular risk factors like hypertension, diabetes, and smoking can lead to increased thromboembolism and atherosclerosis. The management of ET focuses primarily on the prevention of thrombosis and hemorrhage. It involves cardiovascular risk management and antiplatelet and cytoreductive therapy according to the risk stratification. Low-risk ET patients are treated with low-dose aspirin, and high-risk ET patients are treated with cytoreductive therapy with hydroxyurea. Interferon (IFN) and anagrelide are reserved for young patients or pregnant women. This case report discusses a 40-year-old male, a known smoker presenting with myocardial infarction and left anterior descending artery (LAD) blockage without any prior history. His high platelets and the relative absence of cardiovascular risk factors helped reach the diagnosis, and bone marrow analysis and mutation analysis confirmed the diagnosis. The patient was started on hydroxyurea, which decreased the total platelet count.

A Case of Delayed Treatment in Cervical Spondylotic Myelopathy Presenting as Hemiplegia in an Elderly Female.

Cervical spondylotic myelopathy (CSM) is a degenerative disease of the spine that occurs mainly in the elderly, along with age-related changes in the spine. It has a varied presentation, from nonspecific paraesthesia and neck pain to hemiplegia and paraplegia, even quadriplegia, due to the compression of the cervical spine or nerves in the spinal canal or foramina. The diagnosis is often delayed, and cases may present as acute worsening and even hemiplegia mimicking stroke following trauma or neck manipulation. We present a case of CSM in an elderly female presenting with hemiplegia. There was a good recovery after surgical decompression. This case highlights the importance of a high index of suspicion and early diagnosis.

A Rare Presentation of Granulomatosis With Polyangiitis with Multiple Cardiac Valvular Insufficiencies.

Granulomatosis with polyangiitis (GPA), earlier known as Wegener's granulomatosis, is an autoimmune inflammatory disorder that causes necrotizing vasculitis of small- and medium-sized blood vessels. It primarily affects the upper respiratory tract, lungs, and kidneys. Most of the cardiac involvement tends to be subclinical and is often not clinically apparent with involvement of the conduction pathway; myocarditis, pericarditis, or coronary artery involvement are associated with increased morbidity and mortality. These present with the symptoms of shortness of breath, cough, bilateral pedal edema, orthopnea, syncope, and features of heart failure such as elevated jugular venous pressure. We report a rare case of heart involvement with profound valvular deformity involving all four cardiac valves along with renal impairment in a 76-year-old female with recently diagnosed granulomatosis with polyangiitis.

A Case Report of a Prevertebral Mass in an Elderly Male Post Hodgkin's Lymphoma.

Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory autoimmune disease characterized by tissue infiltration by dense lymphoplasmacytic infiltrate composed of T cells, activated B-cells, and plasma cells expressing IgG4 and has varied presentations with similar histopathology. It can involve visceral organs, glands, aorta, lymph nodes, and retroperitoneal tissue. In our case, a 68-year-old male with a past history of Hodgkin's lymphoma and in remission presented for investigation of polyclonal gammopathy. Serum electrophoresis showed increased free kappa light chains, free lambda light chains, and kappa lambda ratio; immunoglobulin G (IgG) levels were also increased. A positron emission tomography (PET) scan and magnetic resonance imaging (MRI) thoracic spine suggested a hypermetabolic prevertebral soft tissue density. Biopsy of the mass suggested IgG4-related disease (IgG4-RD). He also had a compression fracture of the T7 vertebra. He was started on intravenous methylprednisolone and rituximab, following which he had a significant decrease in the size of the mass along with a decline in the levels of IgG, kappa, and lambda chains.

A Case Report of Successful Management of Refractory Polyarticular Gout With Pegloticase.

Gout is inflammatory arthritis and is easily recognizable by healthcare providers by its typical clinical presentation of acute gout flare or by the presence of chronic tophaceous deposits. However, chronic gouty arthropathy can be more challenging to diagnose in some cases, especially in the absence of a previous history of gout and other characteristic findings on exam. We present a case of chronic gouty arthropathy with features mimicking rheumatoid arthritis involving multiple small joints of hands and feet and other large joints. He had high serum uric acids and a dual-energy CT (DECT) scan of the feet and ankles was obtained which showed polyarticular gout. He was started on pegloticase in view of joint erosions, and severe limitations in activity which resulted in a lowering of monosodium urate crystals and symptomatic improvement.

An Interesting Case of Mixed Dust Pneumoconiosis With Progressive Massive Fibrosis and Cor Pulmonale in a South American Farmer.

Pneumoconiosis is an occupational disease found in workers with environmental exposure to organic and inorganic dust, as in mining, sandblasting, pottery, stone masonry, and farming. The inflammatory response of the lung to respirable dust causes the formation of macules, nodules, and fibrosis, and higher silica content in inhaled dust is associated with increased fibrosis. Mixed dust pneumoconiosis (MDP) is characterized by exposure to dust containing 10-20% silica, and its lung imaging show irregular opacities. Histopathology plays a vital role in the diagnosis of MDP. Though it has a favorable outcome, it evolves slowly over many years of constant exposure and is characterized by worsening dyspnea and cough gradually progressing to cor pulmonale. The only effective treatment is removing exposure, which makes it essential to recognize the disease early for a favorable outcome. We present a case of mixed dust pneumoconiosis in a farmer from South America who had asthma. He presented with worsening dyspnea and multiple nodules in both lungs on imaging and cor pulmonale. An extensive workup was done, and it ruled out any malignancy and tuberculosis. Analysis of video-assisted thoracoscopic surgery (VATS) biopsy samples confirmed the diagnosis of mixed dust pneumoconiosis. He had a confluence of irregular nodes in the upper lobes of the lungs, and the largest was 2.1 cm. This fits the International Labour Organization (ILO) definition of progressive massive fibrosis. This, along with cor pulmonale present in him, gives it a poor prognosis even after he is removed from dust exposure. He received steroids, which led to symptomatic improvement, and he was discharged to follow up with the pulmonologist.

Measuring Epidemiologic Effects of Enterococcal Bacteremia and Outcomes From a Nationwide Inpatient Sample Database.

Introduction Enterococcus is a gram-positive, non-sporing, facultative anaerobe. It is a common cause of nosocomial infections in the United States. Enterococcal bacteremia is primarily a nosocomial infection in the medical intensive care unit (ICU), with a preference for elderly patients with multiple comorbidities.  Material and methods This is a retrospective cohort study using the publicly accessible National (Nationwide) Inpatient Sample (NIS) database from October 2015 to December 2017. We examined data from 75,430 patients aged 18 years and older in the NIS who developed enterococcal bacteremia, as identified from the ICD-10 CM codes (B95), to discuss the epidemiologic effects and outcomes of enterococcal bacteremia. Patients were classified based on demographics, and comorbidities were identified. Three primary outcomes were studied: in-hospital mortality, length of stay, and healthcare cost. The secondary outcome was identifying any comorbidities associated with enterococcal bacteremia. Length of stay was defined as days from admission to discharge or death. Healthcare costs were estimated from the hospital perspective from hospital-level ratios of costs-to-charges. SAS 9.4 (2013; SAS Institute Inc., Cary, North Carolina, United States) was used for univariate and multivariate analyses. For data analysis, mortality was modeled using logistic regression. Length of stay and costs were modeled using linear regression, controlling for patient and hospital characteristics. Statistical analyses were performed using SAS. Statistical significance was defined as P<0.05. Results A total of 75,430 patients with enterococcal bacteremia were included in the study. Of this, 44,270 were males and 31,160 females. A total of 50,270 (68.67%) were Caucasians, 11,210 (15.31%) were African Americans, 6,445 (8.80%) were Hispanic and 2,025 (2.77%) were native Americans. Important comorbidities were congestive heart failure (25.91%), valvular disease (8.08%), neurological complications (11.87%), diabetes mellitus with complications (18.89%), renal failure (28.52%), and obesity (11.61%). In-hospital mortality was 11.07%, length of stay was 13.8 days, and a healthcare cost of 41,232.6 USD.  Conclusions Enterococcal bacteremia is a nosocomial infection with a preference for the elderly with renal failure, cardiac failure, cardiac valvular diseases, stroke, obesity, and diabetes with complications. Further studies are needed to see whether the mortality caused by enterococcal bacteremia is attributable to comorbidities or to the bacteremia. It is associated with a more extended hospital stay and higher healthcare expenditure. Implementing contact precautions to contain the spread of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus(VRE) has also checked the spread of enterococci. Further prospective studies can be planned using chart-based data.

A Rare Case of Horseshoe Kidney With Multiple Atrial Myxomas Presenting as Cerebrovascular Accident.

Myxomas are benign tumors of mesenchymal origin, containing a few pluripotent cells in the myxomatous stroma. They usually present at 30-40 years of age and are more common in females than males. These tumors mostly arise in the atria and protrude into the atrial lumen. They cause constitutional symptoms like fever and weight loss and obstructive symptoms related to outflow obstruction in the heart. Some tumors are more fragile and cause embolism and may present as stroke. Mostly sporadic but familial cases and myxomas associated with Carney syndrome (CNC) tend to be multiple. Here, we report a case of a 40-year-old female with a stroke due to embolization from multiple myxomas. She had no family history of myxoma and had no skin findings or other tumors associated with CNC. She also had an atrophied horseshoe kidney with renal failure. The association of a horseshoe kidney with myxoma is rarely reported. In an extensive literature search, we could only find only one other case. Atrial myxomas were detected while investigating the cause of stroke. Our patient gradually improved and was advised surgical removal of the myxomas, which is the treatment of choice.

Dexmedetomidine-Induced Fever in a 66-Year-Old Male With Pneumonia and Pleural Effusion.

Drug-induced fever is a significant adverse effect as many commonly used medications can cause this. The incidence of drug fever is even higher in critical care settings because multiple medications are being administered simultaneously. This poses a serious problem in critical care settings as any new fever in these settings also implies any new infection or worsening of preexisting conditions. This may lead to a detailed investigation for the cause of fever, which can be time-consuming, invasive, costly, and may also increase the duration of stay along with an associated increase in morbidity and mortality. We want to highlight an adverse drug event through a documented case of Dexmedetomidine-induced fever in a critical care patient with multiple pathologies.

Yersinia Enterocolitica Sepsis in an Elderly Male With No Iron Overload: A Case Report From the Northeastern United States.

Yersinia enterocolitica (YE) is a facultative anaerobic gram-negative coccobacillus of the genus Yersinia (the most common ones are YE serogroups O:3; O:5,27; O:8; and O:9). Its incubation period is typically 1-14 days. The symptoms of YE infection include fever, abdominal pain (which may mimic appendicitis), and diarrhea (which may be bloody and can persist for several weeks). It is most commonly reported in infants and children due to cross-contamination of their feeds and pacifiers by people handling pork products, especially while cooking chitterlings. Necrotizing enterocolitis has been described in infants following YE infections. Adults who are immunocompromised or in an iron-overload state can develop sepsis with YE infection, which has a high fatality rate. Post-infectious sequelae like reactive arthritis and erythema nodosum can occur in certain HLA types. The diagnosis is made by isolating the organism from the body fluids, stool. The gastrointestinal (GI) pathogen panel by polymerase chain reaction (PCR) is helpful in making an early diagnosis. In this report, we discuss a case of an elderly male from a nursing facility who presented with abdominal pain, vomiting, GI bleeding, and sepsis. He required a brief ICU stay and pressor support. GI pathogen panel was instrumental in the early diagnosis of YE. This condition is not often reported in the Northeastern US. Using GI pathogen PCR testing will lead to the detection of more cases of YE in geographical regions where it was not considered prevalent.