Severe Acute Respiratory Syndrome Coronavirus 2 Omicron Variant in Patients with Philadelphia-Negative Myeloproliferative Neoplasm: A Single Center Experience.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the viral agent responsible for the coronavirus disease of 2019. The disease is primarily a respiratory illness; however, multisystem involvement is not uncommon. The infection is reported to be more severe in patients with multiple comorbidities and immunocompromised patients. Patients with hematological malignancies are immunocompromised and prone to develop severe SARS-CoV-2 infection. The SARS-CoV-2 had developed several mutations that resulted in different strains with different virulence and different degree of protection by vaccination or prior infection. The Omicron variant is reported to cause mild illness; however, the effect on patients with hematological malignancies like myeloproliferative neoplasms (MPNs) is not clear. We present patients with MPNs who had infection with the Omicron variant of the SARS-CoV-2 and their outcomes. METHODS: Retrospective data from the National Center for Cancer Care and Research records from December 20, 2021, to January 30, 2022. Participants were adults over the age of 18 years with Omicron infection who had been diagnosed with Philadelphia-negative MPNs, essential thrombocythemia, polycythemia vera (PV), and primary myelofibrosis according to the 2008/2016 WHO classification for MPN. RESULTS: Twenty-two patients with Philadelphia-negative MPN had Omicron infection. All patients had a mild disease according to the WHO classification of COVID-19 severity. Most of the patients had medical comorbidities, with hypertension being the most common comorbidity. However, only one patient with PV required hospitalization. DISCUSSION/CONCLUSIONS: In patients with Philadelphia-negative MPN, the Omicron variant of SARS-CoV-2 usually results in mild infection.

Profound metabolic acidosis in association with sodium thiosulfate therapy in a patient with calcific uremic arteriolopathy: a case report and literature review.

Calciphylaxis, also known as Calcific uremic arteriolopathy (CUA), is a serious disorder that presents with skin necrosis due to calcification of dermal and subcutaneous adipose tissue capillaries and arterioles. The condition occurs primarily in patients with end-stage renal disease (ESRD) on dialysis, and it carries high morbidity and mortality, primarily due to sepsis, with an estimated six-month survival of approximately 50%. Although there are no high-quality studies to guide the optimal treatment approach for patients with calciphylaxis, many retrospective studies and case series support treatment with sodium thiosulfate (STS). Despite the frequent use of STS as an off-label treatment, data regarding its safety and efficacy are limited. STS has generally been considered a safe drug with mild side effects. However, severe metabolic acidosis associated with STS is a rare and life-threatening complication of STS treatment and is often unpredictable. Herein, we report a 64-year-old female with ESRD on peritoneal dialysis (PD) who presented with a profound high anion gap metabolic acidosis and severe hyperkalemia while on STS treatment for CUA. No other etiology for her severe metabolic acidosis other than STS was identified. ESRD patients receiving STS should be monitored closely for this side effect. Dose reduction, increasing the duration of infusion, or even discontinuing STS treatment should be considered if severe metabolic acidosis develops.

A Rare Case of Granulomatous Mastitis Associated With Positive Systemic Lupus Erythematosus Serology in a Young Female Patient: A Case Report and Literature Review.

Granulomatous mastitis (GM) is a rare benign breast disease that affects women of childbearing age, usually within five years of pregnancy. The hallmark diagnostic feature of GM is the presence of lobular granulomatous inflammation. The occurrence of this clinicopathological entity is usually idiopathic. Nevertheless, GM has often been associated with systemic inflammatory conditions of either infectious (such as tuberculosis) or autoimmune etiology (particularly sarcoidosis, vasculitis, and less likely systemic lupus erythematosus [SLE]). In this report, the authors described an unusual case of GM that was associated with features of SLE in a young female patient who presented with a painful breast lump. Histopathological examination of the lump's biopsy showed GM. Further laboratory workup revealed evidence of some immunological criteria of SLE. Steroid therapy led to the resolution of the patient's breast swelling. The breast mass remained in remission with hydroxychloroquine treatment. Only a handful of similar cases in the current literature demonstrated a plausible association between SLE and GM. Our case provides a reference to consider SLE as a possible differential diagnosis when GM is encountered in young-aged female patients.

A Rare Pathogen of Bones and Joints: A Systematic Review of Osteoarticular Infections Caused by Gemella morbillorum.

Osteoarticular infections (OAIs) caused by Gemella morbillorum (G. morbillorum) are a rare clinical entity. This study aimed to review all published cases of OAI due to G. morbillorum. A systematic review of PubMed, Scopus, and Cochrane Library was conducted to report the demographic and clinical characteristics, microbiological data, management, and outcome of OAIs caused by G. morbillorum in the adult population. A total of 16 studies reporting on 16 patients were included in this review. Eight patients had arthritis and eight patients had osteomyelitis/discitis. The most reported risk factors were immunosuppression, poor dental hygiene/dental infections, and recent gastrointestinal (GI) endoscopy. Five cases of arthritis occurred in a native joint while three patients had prostheses. The potential source of G. morbillorum infection was documented in more than half of the cases (56%) (most commonly odontogenic and GI sources (25% and 18%, respectively). The knee and hip joints were the most frequently affected joints in patients with arthritis, while the thoracic vertebrae were the most common sites for osteomyelitis/discitis. The blood cultures were positive in three patients with arthritis (37.5%) and five patients with osteomyelitis/discitis (62.5%). Associated endovascular infection was found in five patients with bacteremia. Contiguous spread (adjacent mediastinitis) was documented in two patients with sternal osteomyelitis and thoracic vertebral osteomyelitis. Surgical interventions were performed for 12 patients (75%). Most strains of G. morbillorum were susceptible to penicillin and cephalosporins. All patients with reported outcomes had achieved complete recovery. G. morbillorum is an emerging pathogen for OAIs in certain susceptible populations with specific risk factors. This review reported the demographic, clinical, and microbiological features of OAIs caused by G. morbillorum. A careful evaluation of an underlying infectious focus is warranted to control the source. When G. morbillorum bacteremia is present, it is also necessary to have a high index of suspicion to rule out an associated endovascular infection.

A Case Series of Non-Tuberculous Mycobacterial Pulmonary Disease Masquerading as Malignancy From a Community-Based Hospital.

Non-tuberculous mycobacteria (NTM) are ubiquitous organisms in the environment that can potentially cause a range of pulmonary and extrapulmonary infections in humans. Epidemiological risk factors and the host's immune status determine the susceptibility to various clinical syndromes caused by different NTM species. Non-tuberculous mycobacteria pulmonary disease (NTM-PD) is primarily reported in patients with underlying lung disease. These infections often pose a significant disease burden on affected patients as they are often chronic, difficult to treat, and necessitate long-term multi-drug therapy. Mycobacterium avium complex (MAC) is the most common causative pathogen of NTM-PD in the USA, followed by Mycobacterium kansasii (M. kansasii). Less common species in the USA include Mycobacterium xenopi (M. xenopi), Mycobacterium abscessus, and others, largely depending upon the geographic location and exposure to species-specific predisposing risks. In this case series, the authors report on three elderly patients with chronic lung diseases who had pulmonary NTM disease caused by M. xenopi and MAC. The patients were encountered in both inpatient and outpatient settings from a community-based hospital in the midwestern USA. The clinical and radiological features of NTM-PD masqueraded as malignancy and posed a diagnostic dilemma. The epidemiology, clinical and radiological features, diagnosis, and management of NTM-PD are reviewed in this report.

Persistent Norovirus infection in a young patient with renal transplant: The challenging cost of immunosuppression and the negative impact on patient's quality of life.

Norovirus (NoV) is one of the most common causes of acute infectious gastroenteritis in the United States (US). The infection is typically short-lasting and self-limiting in immunocompetent hosts. Renal transplant recipients on immunosuppressive therapy are more prone to infectious gastroenteritis that can be caused by various common and opportunistic organisms. NoV infection in renal transplant patients presents as an acute diarrheal illness that may progress to a chronic infection with frequent relapses leading to adverse short-term complications (acute renal injury (AKI) and acute graft rejection from the reduction of the dose of immunosuppressive medications) and possibly long-term morbidities (malabsorption syndrome, and a decline in graft survival). The management of chronic NoV infections in renal transplant patients may be quite challenging, as no specific antiviral treatment is presently approved, and frequent adjustments of immunosuppressive therapy may be required in the setting of reduced renal clearance and the attempts to decrease immunosuppressive effects to enhance the viral clearance.Herein, the authors present a case of persistent NoV in a young female patient with a renal transplant that was associated with recurrent admissions with AKI, gross electrolyte disturbances, and significant weight loss. The relapsing NoV infection has negatively impacted the patient's quality of life and socioeconomic performance.

Metastatic Squamous Cell Carcinoma From Primary Hypopharynx Source to Gastric Mucosa Presenting as Massive Gastrointestinal Bleeding.

Percutaneous endoscopic gastrostomy (PEG) is a relatively safe procedure that represents an important supportive adjunctive component for patients with primary head and neck squamous cell carcinoma (HNSCC). The HNSCC population is considered a high-risk group for developing critical nutritional deficiency due to a multitude of factors. Nevertheless, as the use of PEG in modern practice is gaining more popularity due to various indications, unusual complications have been increasingly reported. PEG site metastasis from primary HNSCC has emerged as a rare, yet serious oncological phenomenon that warrants careful consideration. The authors report an unusual case of squamous cell carcinoma (SCC) of the hypopharynx that metastasized to the gastric body mucosa through a PEG site. The metastatic SCC presented as massive gastrointestinal bleeding, and esophagogastroscopy revealed an ulcerated mass in the gastric body masquerading as a primary gastric adenocarcinoma. Histopathology and immunohistochemistry examination confirmed metastatic SCC which concurred with the patient's primary hypopharyngeal SCC. The review of the updated literature revealed that a total of 121 cases of this rare oncological entity have been reported to date. Physicians need to be vigilant of the symptoms of PEG site metastasis to accurately diagnose and manage the care of this rare occurrence as it is associated with poor prognosis.

Subarachnoid Hemorrhage From Cavernous Malformation Masquerading as Myocardial Infarction.

Intracranial hemorrhage, including subarachnoid hemorrhage (SAH), is associated with many cardiac effects, including cardiac rhythm abnormalities, ischemic electrocardiographic (ECG) changes, elevated cardiac troponin levels, and regional wall motion abnormalities on echocardiogram. About 40% of patients with SAH demonstrate increased serum markers for myocardial necrosis. Approximately 10% of patients with SAH demonstrate left ventricular (LV) wall motion abnormalities; a subset of these patients will have irreversible myocardial damage, but most regain LV function in several weeks. Cardiac effects of SAH are thought to be a result of an imbalance of the autonomic nervous system with resultant increased catecholamine effect on the myocardial cells rather than due to preexisting coronary artery disease. These cardiovascular complications carry a prognostic significance in patients with SAH and can also be misdiagnosed as primary cardiac problems and delay the diagnosis of SAH. Herein, we present a case of a 68-year-old female who presented to the emergency department with acute onset of upper back and neck pain. She was initially misdiagnosed with myocardial infarction in view of the ischemic changes in the ECG and elevated cardiac troponins. She was started on antiplatelets and anticoagulation but was later found to have a negative coronary angiography and was diagnosed with SAH via a computed tomography (CT) scan. Intracranial hemorrhage can be associated with elevated cardiac enzymes and ECG changes and can sometimes masquerade as an acute coronary syndrome (ACS). A careful history and examination and a high index of clinical suspicion are pivotal in such cases since early diagnosis significantly impacts prognosis and prevents the inadvertent use of antiplatelets and anticoagulation, which can be detrimental if used in such cases.

Electric Cardioversion vs. Pharmacological with or without Electric Cardioversion for Stable New-Onset Atrial Fibrillation: A Systematic Review and Meta-Analysis.

BACKGROUND: There is no clear consensus on the preference for pharmacological cardioversion (PC) in comparison to electric cardioversion (EC) for hemodynamically stable new-onset atrial fibrillation (NOAF) patients presenting to the emergency department (ED). METHODS: A systematic review and meta-analysis was conducted to assess PC (whether being followed by EC or not) vs. EC in achieving cardioversion for hemodynamically stable NOAF patients. PubMed, PubMed Central, Embase, Scopus, and Cochrane databases were searched to include relevant studies until 7 March 2022. The primary outcome was the successful restoration of sinus rhythm, and secondary outcomes included emergency department (ED) revisits with atrial fibrillation (AF), hospital readmission rate, length of hospital stay, and cardioversion-associated adverse events. RESULTS: A total of three randomized controlled trials (RCTs) and one observational study were included. There was no difference in the rates of successful restoration to sinus rhythm (88.66% vs. 85.25%; OR 1.14, 95% CI 0.35-3.71; n = 868). There was no statistical difference across the two groups for ED revisits with AF, readmission rates, length of hospital stay, and cardioversion-associated adverse effects, with the exception of hypotension, whose incidence was lower in the EC group (OR 0.11, 95% CI 0.04-0.27: n = 727). CONCLUSION: This meta-analysis suggests that there is no difference in successful restoration of sinus rhythm with either modality among patients with hemodynamically stable NOAF.

Mycobacterium tuberculosis epidemiology in Oman: whole-genome sequencing uncovers transmission pathways.

Tuberculosis (TB) originating from expatriates that hail from high TB-burden countries is hypothesized to play a role in continued TB transmission in Oman. Here, we used whole-genome sequencing (WGS) to assess national TB transmission dynamics. The annual incidence per 100,000 population per year was calculated for nationals and expatriates. A convenience sample of Mycobacterium tuberculosis (MTB) isolates from 2018 to 2019 was sequenced and analyzed with publicly available TB sequences from Bangladesh, Tanzania, the Philippines, India, and Pakistan. Relatedness was assessed by generating core-genome single nucleotide polymorphism (SNP) distances. The incidence of TB was five cases per 100,000 persons in 2018 and seven cases per 100,000 persons in 2020 (R2 = 0.34, P = 0.60). Incidence among nationals was 3.9 per 100,000 persons in 2018 and 3.5 per 100,000 persons in 2020 (R2 = 0.20, P = 0.70), and incidence among expatriates was 7.2 per 100,000 persons in 2018 and 12.7 per 100,000 persons in 2020 (R2 = 0.74, P = 0.34). Sixty-eight local MTB isolates were sequenced and analyzed with 393 global isolates. Isolates belonged to nine distinct spoligotypes. Two isolates, originating from an expatriate and an Omani national, were grouped into a WGS-based cluster (SNP distance < 12), which was corroborated by an epidemiological investigation. Relatedness of local and global isolates (SNP distance < 100) was also seen. The relatedness between MTB strains in Oman and those in expatriate countries of origin can aid inform TB control policy. Our results provide evidence that WGS can complement epidemiological analysis to achieve the End TB strategy goal in Oman. IMPORTANCE Tuberculosis (TB) incidence in Oman remains above national program control targets. TB transmission originating from expatriates from high TB-burden countries has been hypothesized to play a role. We used whole-genome sequencing (WGS) to assess TB transmission dynamics between expatriates and Omani nationals to inform TB control efforts. Available Mycobacterium tuberculosis isolates from 2018 to 2019 underwent WGS and analysis with publicly available TB sequences from Bangladesh, the Philippines, India, and Pakistan to assess for genetic relatedness. Our analysis revealed evidence of previously unrecognized transmission between an expatriate and an Omani national, which was corroborated by epidemiological investigation. Analysis of local and global isolates revealed evidence of distant relatedness between local and global isolates. Our results provide evidence that WGS can complement classic public health surveillance to inform targeted interventions to achieve the End TB strategy goal in Oman.

Extensive Aortic Thrombosis and Renal Infarction in Association With an Active Flare-Up of Crohn's Disease.

Venous thromboembolism (VTE) is a recognized extraintestinal manifestation of inflammatory bowel disease (IBD), with deep venous thrombosis (DVT) and pulmonary embolism being reported as the most frequent vascular complications in IBD patients. Much less frequently, arterial thromboembolic events may also be associated with greater morbidity and mortality. Aortic mural thrombosis is a rare phenomenon described in patients with IBD that often results in serious consequences such as visceral infarction and acute ischemia of the lower extremities. We described an unusual case of a female patient with Crohn's disease (CD) who presented with generalized abdominal pain and vomiting. Imaging showed an active flare-up of intestinal CD as well as two mural thrombi in the distal descending thoracic aorta and the abdominal aorta at the level of the left renal artery, respectively, with a left renal infarction. The mesenteric angiogram revealed a patent celiac axis and mesenteric arteries. The patient was therapeutically anticoagulated, and she underwent a right hemicolectomy for the perforated ileal disease. A comprehensive diagnostic workup for hypercoagulability and thrombophilia was negative for an underlying etiology, and the active CD flare-up was considered the main culprit triggering the aortic thrombosis in this reported patient. Our case highlighted the occurrence of aortic thrombosis in a patient with IBD and that entails careful attention. Early recognition and timely management with a multidisciplinary team is the key to improving the outcome of aortic events that coincide with the active flare-up of IBD.

Leuprolide-Induced Hyperosmolar Hyperglycemic State in an Elderly Patient: A Case Report and Literature Review.

We present a novel case of severe hyperosmolar hyperglycemic derangement in an elderly patient - without a known history of diabetes mellitus - after the first injection of leuprolide for the treatment of metastatic prostate adenocarcinoma. Whilst the available literature provided accumulative evidence of an association between insulin resistance and the use of gonadotropin-releasing hormone (GnRH) agonists, the initial presentation of leuprolide-induced impaired glycemic tolerance with a hyperosmolar hyperglycemic state (HHS) represents a clinical rarity that was seldom reported. A literature review was conducted to explore the underlying mechanisms of leuprolide-associated glucose intolerance. Screening for diabetes is recommended for patients receiving leuprolide therapy to identify at-risk patients and close glycemic monitoring is warranted in diabetic patients to minimize serious complications from poor glycemic control induced by leuprolide.

Tocilizumab-Associated Small Bowel Perforation in a Young Patient With Rheumatoid Arthritis: A Lesson to Remember During COVID-19 Pandemic.

Tocilizumab is a recombinant humanized monoclonal antibody directed against the interleukin-6 (IL-6) receptor, which has been used for the treatment of rheumatoid arthritis (RA). A range of side effects have been associated with tocilizumab, with gastrointestinal perforation (GIP) being described as a rare but potentially life-threatening complication that deserves considerable attention. The authors report a case of a young male patient with a history of challenging RA who encountered a lower GIP that was associated with tocilizumab therapy. The occurrence of tocilizumab-induced GIP in this reported patient had initially posed a diagnostic dilemma, as its clinical presentation mimicked other autoimmune inflammatory and infectious diseases that are commonly associated with RA. Physicians should be aware of GIPs as a serious adverse event of tocilizumab use despite being a rare phenomenon, particularly in the era of the global pandemic of coronavirus disease 2019 (COVID-19), when this novel drug has been authorized for the management of selected patients with severe COVID-19 infection. Therefore, early recognition and timely management of GIPs would minimize potential morbidities associated with critically ill COVID-19 patients.

Gemella morbillorum as the Culprit Organism of Post-Colonoscopy Necrotizing Perineal Soft Tissue Infection in a Diabetic Patient With Crohn's Disease.

Gemellsa morbillorum (G. morbillorum) is a Gram-positive facultative anaerobe and a known commensal organism of the oropharyngeal and gastrointestinal tracts. It is considered a rare cause of infections in humans. Most of the documented infections, whereas G. morbillorum has been implicated as a causative pathogen, were infective endocarditis and deep visceral abscesses. However, there are only a handful of cases in the current literature that have reported G. morbillorum as the primary organism causing necrotizing soft tissue infections. The authors presented a rare case of post-colonoscopy necrotizing perineal soft tissue infections in an elderly patient with poorly controlled diabetes mellitus and Crohn's disease with G. morbillorum being the culprit pathogen of this necrotizing infection. The reported case raises concerns for this commensal organism as an emerging virulent pathogen in certain high-risk patients. The authors proposed that a combination of the long-standing Crohn's disease and the recent colonoscopy with rectal polypectomy has predisposed the patient to G. morbillorum bacteremia with perineal sepsis in the setting of diabetic immunosuppression. Further studies are warranted to ascertain whether G. morbillorum is acquiring increased virulence that would have enabled this organism to cause novel soft tissue infections.

A Suspicious Hilar Mass Revealing an Uncommon Diagnosis of Pulmonary Actinomycosis in an Immunocompromised Young Female Patient: A Case Report and Literature Review.

 Actinomycosis is a chronic inflammatory infectious disease that can affect various organ systems. Pulmonary actinomycosis is an exceptionally uncommon clinical occurrence that yet deserves special attention, as it closely mimics a broad spectrum of infectious and neoplastic lung pathologies. The non-specific nature of its clinical features and radiological appearances makes early diagnosis quite challenging. The authors reported a 25-year-female with poorly controlled diabetes mellitus and morbid obesity who presented with a one-week history of unilateral, right-sided, pleuritic chest pain and shortness of breath. Chest imaging revealed a suspicious right hilar soft tissue mass encasing the right upper lobe bronchus with post-obstructive atelectasis. Transbronchial biopsy revealed suppurative granulomatous inflammation, and anaerobic cultures from the bronchial tissues grew Actinomyces species that were identified using the matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) technique. A long course of penicillin-based antibiotics was employed, and follow-up imaging revealed a satisfactory response to the antimicrobial therapy. This case demonstrates that microbiological examination is imperative to accurately diagnose the etiology of suspicious lung masses in young immunocompromised hosts. It also proves the diagnostic value of the MALDI-TOF technique in the early identification of Actinomyces species.

Pulmonary Kaposi Sarcoma as an Unusual Etiology of Acute Hypoxemic Respiratory Failure in the Era of Highly Active Antiretroviral Therapy: A Case Report.

Kaposi sarcoma (KS) is caused by human herpesvirus 8 (HHV-8). Epidemic KS is described in the human immunodeficiency virus (HIV) population with acquired immune deficiency syndrome (AIDS). It primarily affects the skin, but it may uncommonly disseminate to involve extracutaneous sites such as the gastrointestinal (GI) tract, liver, and lungs. In this case report, the authors report a 26-year-old homosexual male who was admitted with acute hypoxemic respiratory failure. He was diagnosed with an HIV infection about five months before index presentation, and he was commenced on highly active antiretroviral therapy (HAART). Physical examination was remarkable for diffuse cutaneous nodules over the lower extremities, back, and oropharynx. Chest imaging revealed diffuse bilateral infiltrates, mediastinal adenopathy, and a persistent bilateral pleural effusion. Extensive diagnostic workup was negative for underlying infectious etiology. Transbronchial biopsy demonstrated proliferated spindle cells that stained positive for HHV-8 in keeping with pulmonary KS. Skin biopsies also concurred with the diagnosis of cutaneous KS. Interestingly, the cluster of differentiation 4 (CD4) count was 647 cells/mm3, and HIV viral load (VL) was 500 copies/ml. This case demonstrated an atypical natural history of pulmonary KS in an HIV patient as pulmonary and disseminated mucocutaneous KS occurred with a relatively higher CD4 count (≥500 cells/mm3). It also reminds pulmonologists and infectious disease specialists to consider pulmonary KS as a differential diagnosis of acute hypoxemic respiratory failure in HIV patients, even in the absence of other clinical and laboratory criteria that define the AIDS stage.

Omental Fat Torsion: A Rare Mimicker of a Common Condition.

Acute abdomen is a common emergency condition affecting young adults, and the first consideration is usually aimed to rule out acute appendicitis in this age group. Omental fat torsion has emerged as one of the rare etiologies of acute abdomen in the younger population. It warrants serious consideration as it closely mimics acute appendicitis in its clinical presentation. Herein we report a case of omental fat torsion in a 22-year-old male patient who presented with an acute right-sided lower abdominal pain which was highly suggestive of acute appendicitis. However, the diagnostic laparoscopy revealed a normally looking appendix and terminal ileum with an infarcted omental segment on the right side of the greater omentum. A laparoscopic omentectomy and an appendectomy were performed with an uneventful postoperative recovery. The pathology report confirmed omental fat infarction and a normal appendix. This case highlights omental fat infarction as a rare etiology of acute abdomen in a young male patient.

Incomplete Kawasaki Disease in an Infant: A Case Report and Literature Review.

The term "incomplete Kawasaki Disease (IKD)" was first used to describe patients with coronary complications who did not fulfill the classical diagnostic criteria for Kawasaki Disease (KD). The risk of coronary artery involvement is similar if not greater in cases of IKD. However, the recognition of IKD is challenging and often delayed, especially in infants. Multiple algorithms have been formulated to identify cases of IKD utilizing supplemental clinical, echocardiographic, and laboratory features. Although fever is not required for a diagnosis of KD in the Japanese guideline, most of the current guidelines, including those of the American Heart Association (AHA), consider the presence of fever for at least seven days a requirement for the diagnosis of both KD and IKD in infants. We present a case of IKD in a four-month-old female who presented with fever for less than three days and did not follow the current AHA algorithm for IKD. An echocardiogram obtained 10 days later revealed a coronary artery aneurysm, and a retrospective diagnosis of IKD was made. A review of the literature identified similar cases with a growing consensus on the need to redefine the role of fever. Pediatricians should search for coronary artery lesions in cases of high clinical suspicion, even if the fever period is short, particularly in those less than six months. Additionally, further innovative research is directly needed to identify immunological and cellular markers that could be tested early in the course of the disease and guide the management.

The Diagnostic Dilemma of Acute Granulomatous Hepatitis in a Patient With Crohn's Disease: A Case Report and Review of Literature.

Liver involvement is not an uncommon extraintestinal manifestation of inflammatory bowel disease (IBD). IBD-associated liver diseases may have a variety of etiopathogenetic origins (including shared autoimmune pathogenesis, the effect of chronic inflammatory status, and adverse effects of drugs). Nevertheless, acute granulomatous hepatitis in the setting of Crohn's disease (CD) is a rare clinical entity. It warrants, however, a careful assessment as both clinical and pathological features of Crohn's-associated granulomatous hepatitis closely mimic extrapulmonary hepatic sarcoidosis, with considerable overlaps between the 2 diseases, which certainly makes a definitive diagnosis quite challenging. It is crucial to exclude infectious etiologies during the evaluation of acute granulomatous hepatitis, as inappropriate immunosuppressive treatment may cause a systemic flare-up of an underlying liver infection. We report a rare case of a 35-year-old female with a history of CD who presented with recurrent fevers, acute abdominal pain, and cholestasis. She was found to have acute hepatitis with noncaseating granulomas on liver biopsy. A comprehensive diagnostic workup did not ultimately prove a specific etiological culprit. The patient was treated with oral corticosteroids, and she demonstrated a positive clinical and laboratory response to the treatment. Our case highlights the diagnostic dilemma of acute granulomatous hepatitis in the setting of co-existent CD with a multisystemic syndrome. Granulomatous hepatitis represents a relatively rare manifestation of both extraintestinal CD and extrapulmonary sarcoidosis, with potential difficulties discriminating between the 2 entities on many occasions. The case also demonstrates the value of an interdisciplinary approach in the context of multisystemic disease to achieve the best outcome.

Isolated Enteric Myeloid Sarcoma as a Rare Etiology of Small Bowel Obstruction in a Young Female Patient.

Myeloid sarcoma (MS) is an extra-medullary solid tumor consisting of myeloid blasts or immature myeloid cells. MS is usually associated with acute myeloid leukemia (AML) and other myeloproliferative neoplasms or myelodysplastic disorders. Isolated MS is a rare clinical entity, and the small bowel is a rare phenomenon for the occurrence of MS. A 30-year-old African American female patient with a past medical history of asthma presented with acute abdominal pain and vomiting for 3 days. Imaging revealed small bowel obstruction with a transition point at a suspicious mass in the distal ileum mimicking carcinoid tumors. She underwent an uneventful laparoscopic resection of this mass with primary bowel anastomosis. Histopathology of the resected mass revealed immature myeloid cells that stained positive for myeloperoxidase and CD34/CD117, in keeping with a small bowel MS. A bone marrow examination was negative for concurrent AML. Cytogenetic analysis revealed MYH11/CBFB fusion and an inversion 16 chromosomal aberration which are rarely associated with myeloid disorders. The patient was commenced on systemic chemotherapy to achieve remission and prevent progression to AML. The literature is reviewed, and all cases of small bowel MS are presented in this report. Non-leukemic small bowel MS is an exceptional presentation. We described a case of isolated enteric MS, which was associated with a rare MYH11/CBFB fusion and inversion 16 chromosomal aberration. The diagnosis of small bowel MS can be extremely challenging due to the rarity of the disease and non-specific nature of clinical and radiological features. A histopathological examination with immunohistochemistry staining is imperative to establish an accurate diagnosis. Isolated small bowel MS deserves special attention as it warrants systemic chemotherapy to prevent transformation into AML.