Benjamin Koslowsky

Imported Melioidosis, Israel, 2008

In 2008, melioidosis was diagnosed in an agricultural worker from Thailand in the southern Jordan Valley in Israel. He had newly diagnosed diabetes mellitus, fever, multiple abscesses, and osteomyelitis. Burkholderia pseudomallei was isolated from urine and blood. Four of 10 laboratory staff members exposed to the organism received chemoprophylaxis, 3 of whom had adverse events.

Is Needle Aspiration for Peritonsillar Abscess Still as Good as We Think? A Long-term Follow-up:

Objective: The aim was to study the therapeutic management, recurrence, and need for tonsillectomy in patients who underwent needle aspiration for peritonsillar abscess (PTA). Methods: A prospective observational design study was performed. Patients hospitalized in Shaare Zedek Medical Center between the years 2004 and 2007 with a diagnosis of PTA who underwent needle aspiration obtaining pus were included. A minimum 5-year follow-up was required for all patients. Recurrences, complications, the need for a repeated surgical procedure, length of hospital admission, and tonsillectomy were the primary end points. Results: The study included 117 patients. One hundred four patients (88.9%) improved after 1 needle aspiration without any other intervention, whereas 13 patients (11.1%) required an additional procedure. Broad spectrum antibiotics showed a statistical advantage over penicillin only, regarding need for recurrent procedure (14.7% vs 4.7%, P = .02). No short- or long-term complications were documented. Seventeen patients (14.5%) had any recurrence. Primary recurrent tonsillitis, female sex, and younger age were predictive risk factors for recurrent events of PTA (32% vs 10%, P < .01). A total of 18 patients (15.4%) eventually underwent tonsillectomy. Conclusion: Needle aspiration is an effective first line procedure for patients with PTA. Tonsillectomy is not necessary in most cases. In our study, young age, female sex, and recurrent tonsillitis are negative prognostic factors for recurrence. These patients should be managed accordingly. Broad spectrum antibiotics may offer additional advantages when compared to penicillin only.

CMV-related thrombocytopenia treated with foscarnet: A case series and review of the literature

Severe thrombocytopenia as a complication of CMV infection in immune competent adults is uncommon with only a few cases reported in the literature. The mechanism of CMV-related thrombocytopenia is unclear, resulting in a wide range of treatments used. The use of the antiviral agent ganciclovir was reported in five cases, with variable results. The use of foscarnet, which does not share the myelosuppressive effects of ganciclovir, in adult immune competent patients has not been reported. We review the literature and report two cases of CMV-related thrombocytopenia that were treated with foscarnet. In both cases a recent acute infection with CMV was well established and viral eradication following treatment with foscarnet was demonstrated. In one patient thrombocytopenia resolved following treatment with foscarnet and viral eradication. In the other patient, thrombocytopenia resolved following splenectomy, which was performed after viral eradication. Due to the therapeutic consequences of this diagnosis, it may be worthwhile to perform CMV screening in selected patients with thrombocytopenia. In case CMV viremia is demonstrated, viral eradication seems to have a positive influence on the resolution of thrombocytopenia. Foscarnet is a reasonable first line anti CMV agent in this setting.

A prospective study of fecal calprotectin and lactoferrin as predictors of small bowel Crohn's disease in patients undergoing capsule endoscopy

Abstract Background: Capsule endoscopy (CE) is often used to investigate small bowel Crohns disease (CD). Aim: The aim of this study is to prospectively assess the value of fecal calprotectin and lactoferrin to predict CE findings. Patients and methods: Sixty-eight consecutive patients that were referred for CE were included. Stool samples for calprotectin and lactoferrin and blood samples were collected for relevant parameters. Correlation between fecal markers and CE findings was assessed and receiver operating characteristic (ROC) curves were built to determine the predictive values of fecal markers for the diagnosis of CD. Results: Fecal calprotectin data was available for all the patients and lactoferrin data for 38. CE findings compatible with CD were found in 23 (33%) patients and 45 (67%) were negative for CD. The average age of the CD group was 34 compared to 46 in the non-CD group (p = .048). Median calprotectin and lactoferrin in the CD group and in the control group were 169 mg/kg vs. 40 (p = .004) and 6.6 mg/kg vs. 1 (p = .051), respectively. The area under the ROC curve was 0.767 for calprotectin and 0.70 for lactoferrin. A fecal calprotectin concentration of 95 mg/kg and fecal lactoferrin of 1.05 mg/kg had a sensitivity, specificity, positive predictive value and negative predictive value of 77 and 73%, 60 and 65%, 50 and 50%, and 84 and 84% in predicting CE findings compatible with CD. Conclusions: Fecal markers are simple and noninvasive surrogates for predicting CE findings compatible with CD. Fecal markers can help determine which patients should be referred for CE. ClinicalTrials.gov Identifier: NCT01266629

Normal vitamin D levels are associated with spontaneous hepatitis B surface antigen seroclearance

AIM To investigate a possible association between serum vitamin D levels and spontaneous hepatitis B surface antigen (HBsAg) seroclearance. METHODS Fifty-three patients diagnosed with chronic inactive hepatitis B and spontaneous HBsAg seroclearance were followed up in two Israeli liver units between 2007 and 2012. This retrospective study reviewed medical charts of all the patients, extracting demographic, serological and vitamin D rates in the serum, as well as medical conditions and current medical therapy. Spontaneous HBsAg seroclearance was defined as the loss of serum HBsAg indefinitely. Vitamin D levels were compared to all patients who underwent spontaneous HBsAg seroclearance. RESULTS Out of the 53 patients who underwent hepatitis B antigen seroclearance, 44 patients (83%) had normal levels of 25-hydroxyvitamin vitamin D compared to 9 patients (17%) who had below normal levels. Multivariate analysis showed that age (> 35 years) OR = 1.7 (95%CI: 1.25-2.8, P = 0.05), serum vitamin D levels (> 20 ng/mL) OR = 2.6 (95%CI: 2.4-3.2, P = 0.02), hepatitis B e antigen negativity OR = 2.1 (95%CI: 2.2-3.1, P = 0.02), low viral load (hepatitis B virus DNA < 100 IU/mL) OR = 3 (95%CI: 2.6-4.2, P = 0.01) and duration of HBsAg seropositivity (> 8 years) OR = 1.6 (95%CI: 1.15-2.6, P = 0.04) were also associated with spontaneous HBsAg seroclearance. CONCLUSION We found a strong correlation between normal vitamin D levels and spontaneous HBsAg seroclearance.

Inflammatory Bowel Disease: An Emergent Disease Among Ethiopian Jews Migrating to Israel

Background:The development and characteristics of inflammatory bowel disease (IBD) in Ethiopian Jewish immigrants to Israel were investigated. Methods:A case-control study was conducted in 7 tertiary care hospitals in Israel. Patients of Ethiopian origin with IBD >6 months were included. Time of disease onset after immigration and age at diagnosis were recorded. Randomly chosen patients with IBD of Ashkenazi Jewish origin served as controls. Demographics and clinical parameters were compared between the 2 cohorts. Results:Thirty-two Ethiopian patients with IBD were compared with 33 Ashkenazi Jewish patients with IBD. Crohns disease (CD) was more prevalent than ulcerative colitis (UC) in the Ethiopian group compared with the Ashkenazi group (94% versus 73%, P = 0.02). No Ethiopian-origin patient had a positive family history of IBD compared with 42% of Ashkenazi-origin patients (P < 0.001). Arthritis was more common in Ashkenazi than in Ethiopian patients (27% versus 3%, P < 0.01). One Ashkenazi patient with CD had upper gastrointestinal involvement compared with 7 (23%) in the Ethiopian group (P < 0.02). All other clinical measures were similar between the 2 cohorts. The Ethiopian group lived in Israel with a mean of 13 ± 5 years, and 75% were born in Ethiopia. The shortest time between immigration and developing IBD was 8 years (range, 8–26; median 16 yrs). No Ethiopian patient was diagnosed before immigration. Conclusions:Ethiopian Jews migrating to Israel are at risk of developing IBD. Larger cohorts are needed to determine the relative importance of environmental and genetic factors that cause IBD in these patients.

Scattered striated persistent nephrogram in sepsis

Persistent nephrogram, the hallmark of radiocontrast-induced kidney failure, is usually homogenous throughout the kidney and is considered as a generalized shutoff of glomerular filtration, the consequence of altered glomerular hemodynamics, affecting most glomeruli. Herein, we report an incidental finding of scattered persistent nephrogram that was noted in a septic prediabetic hypertensive patient during computerized tomography-guided drainage of a liver abscess. The peculiar patchy striated distribution pattern suggests more centrally altered renal hemodynamics, with hypoperfusion at the level of interlobar and intralobular arteries. Altered renal microcirculation in this case is likely related to the combined effects of prediabetes, sepsis and contrast medium upon renal blood flow regulation, perhaps with consequent focal hypoxic tubular damage.

Unexpected FDG-PET uptake in the gastrointestinal tract: endoscopic and histopathological correlations.

AIM To investigate the nature and significance of unexpected positron emission tomography with fluorodeoxyglucose (FDG-PET) uptake within the gastrointestinal tract (GIT). METHODS Patients with unexpected FDG-PET findings in the GIT were evaluated. All patients had a previous confirmed malignancy, either solid or lymphoproliferative. The radiologic reports were performed by experienced radiologists with an exclusive PET expertise. Endoscopy, i.e., esophagogastroduodenoscopy (EGD) and colonoscopy, and histopathological evaluation of all findings was performed in all patients in accordance to the FDG-PET results. The findings from each of these modalities were compared to each other. Both clinically significant and insignificant findings were assessed. RESULTS Seventy-two patients were endoscopically evaluated. Twenty-seven patients (37.5%) had primarily a lymphoproliferative tumor and 45 (62.5%) had solid tumors. In 50 patients (69.4%) the endoscopic examination revealed lesions in the same anatomical areas as the FDG-PET findings. Among these 50 patients, malignant and premalignant lesions i.e., adenomatous polyps were found in 16 (32%) and 9 (18%) patients, respectively. Inflammation was noted in an additional 20 patients (40%). Compared to primary solid tumors, a background of primary lymphoproliferative malignancy was more likely to reveal an additional primary malignancy (15.6% vs 33.3%, respectively, P < 0.01). EGD compared to colonoscopy, revealed altogether 11 (25.6%) new malignancies compared to 5 (17.2%), respectively, P = 0.12. No GIT clinically significant findings were overseen by the FDG-PET. CONCLUSION Unexpected FDG uptake in the GIT is commonly encountered and may contain significant findings. Endoscopy evaluation is justified in order to detect these additional findings.

P291 “IBD MOM”: report of a new concept in the treatment of IBD in pregnancy

Background: About 25% of women become pregnant after an initial diagnosis of inflammatory bowel disease (IBD). Patients and care givers are challenged by deep concerns on the reciprocal effect of disease and the reproductive outcomes. We planned and established a single center multilevel interdisciplinary concurrent team approach clinic, “IBD MOM” that offers female patients complimentary care with scheduled visits from pre-conception until the postpartum period. We report the outcome of IBD disease activity and pregnancy outcome in patients managed by this unique approach clinic. Methods: This is a prospective cohort study. Medical and perinatal data of the “IBD MOM” Clinic between June 2011 and June 2013 are presented. IBD female patients who were considering pregnancy or during pregnancy were encouraged to apply for consults that provided information and care with regards to fertility therapy, medication safety during pregnancy and breastfeeding, disease evaluation and therapy adjustments and delivery plan. The service was provided in parallel on site by a team including specialists trained in gastroenterology, maternal fetal medicine, general surgery, food regimens, psychology and a coordinator nurse. All data is recorded in the hospital computerized database service. Results: Seventy-five patients, with a mean age of 29±5 years were included in the IBD MOM program evaluation. During the study period, 207 visits took place: 54 (26%) preconception visits, 130 (63%) during pregnancy and 23 (11%) postpartum checkup, culminating in 13 on going pregnancies, one early abortion and 43 deliveries during the study. At conception 46 patients (82%) were in remission, 50 (89%) continued medical therapy during pregnancy. Relapse during the pregnancy occurred in 22 patients (39%). Therapy adjustment included addition of steroids or anti-TNF in 11 patients (48%), optimizing current treatment in 5 (22%), nutritional support in 4 (17%) and a combination of enteral feeding and steroids in 3 (13%). The median gestational age at delivery was 39 weeks. IBD uncontrolled flare up and poor nutritional status were the cause of late preterm induction of labor (36 37 weeks) in 5 patients (12%). The majority of patients had an uncomplicated vaginal birth while 5 (11.6%) delivered by cesarean section (C/S). All live newborns were healthy with median birth weight of 3040±764 grams and 5′ Apgar scores >7. Thirty-nine (90%) women breast fed. Remission persisted in the postpartum period for most of patients 35 patients (83%). Conclusions: An integrated single center concurrent multidisciplinary clinic for the management of female IBD patients had a positive impact on the pregnancy rate and outcome.

Pregnancy-Onset Inflammatory Bowel Disease: A Subtle Diagnosis

Background Inflammatory bowel diseases (IBDs) are commonly diagnosed during the reproductive years. IBD first manifested during pregnancy (pregnancy-onset IBD [POIBD]) is still an undescribed entity. The aim of the study was to evaluate the characteristics and maternal and neonatal outcomes of patients with POIBD. Methods Data of all pregnant women with IBD within a single multidisciplinary referral clinic, IBD-MOM, between 2011-2016, were analyzed. Maternal and neonatal characteristics and outcomes were compared between the POIBD group and those diagnosed before pregnancy (non-POIBD). Results We identified 237 women, 31 (15%) from the POIBD group and 206 (85%) from the non-POIBD group. Eight (3.5%) patients experienced early spontaneous pregnancy loss, all in the non-POIBD group. The POIBD diagnosis occurred in 16 (52%) patients during the first trimester, 10 (32%) in second trimester, and 5 (16%) during third trimester. Diagnosis of ulcerative colitis (UC) was significantly more common in the POIBD group compared with the non-POIBD group (22/31, 71% vs 50/206, 24%, respectively, P < 0.001). More UC than Crohns disease patients had active disease during pregnancy (69% vs 50%, P = 0.03, respectively). POIBD patients experienced vaginal delivery in 100% of births, compared with 164 (79.6%) in the non-POIBD group (P = 0.017). The mean gestational age at birth and the neonatal weight were similar among the study groups; 38.6 weeks and 3040 g for POIBD patients, compared with 38.7 weeks and 3055 g in the non-POIBD group. Conclusions POIBD is a unique clinical entity, and the diagnosis is mostly UC. However, the maternal and neonatal outcomes are similar.