Jayakrishna Chintanaboina

An Unusual Occurrence of Hepatic Granulomas and Secondary Sitosterolemia in Turner Syndrome

Although abnormal liver function tests occur in 50–80% of cases with Turner syndrome, there are no previous reports of overt hepatic disease or hepatic granulomas associated with Turners syndrome. We report three cases of Turner syndrome associated with hepatic granulomas with a wide range of liver dysfunction. Of the three patients, first patient underwent liver transplantation; second patient remained stable on immunosuppressants; and third patient died from complications of decompensated liver cirrhosis as she declined liver transplantation due to multiple comorbidities. One patient had sitosterolemia, a rare inherited autosomal recessive disorder of cholesterol metabolism, after she ingested β-sitosterol supplement and had worsening liver function tests and lipid panel. She had remarkably abnormal lipid panel that responded to ezetimibe and by stopping the β-sitosterol supplement.

Recurrent Acute Pancreatitis Probably Induced by Rosuvastatin Therapy: A Case Report

Context. Approximately 1.4–2% of all cases of acute pancreatitis are drug related in general population. The literature on statin-induced pancreatitis consists primarily of anecdotal case reports. We report a case of possible rosuvastatin-induced pancreatitis. Case Report. A 67-year-old female presented with progressively worsening abdominal pain and vomiting for 7 days. Home medications included rosuvastatin and clonidine. CT scan of abdomen, with intravenous contrast, showed findings consistent with acute pancreatitis. She responded to conservative management. Rosuvastatin was resumed at the time of discharge from the hospital, and she presented two months later with recurrence of acute pancreatitis. Further workup ruled out all likely causes of acute pancreatitis. Rosuvastatin was stopped completely when she was discharged the second time, and she did not have any further episodes of acute pancreatitis. She was completely asymptomatic throughout the 18-month follow-up period. Conclusion. This paper reinforces the possible association of rosuvastatin, a novel statin, with acute pancreatitis, even though the exact underlying mechanism of statin-induced pancreatitis remains unknown.

Recurrent Mitral Valve Endocarditis Caused by Streptococcus pneumoniae in a Splenectomized Host

A 72-year-old male with a remote history of splenectomy and two previous episodes of pneumococcal endocarditis of mitral valve presented with high-grade fever and confusion for 3 days. Nine months priorly, patient underwent mitral valve repair when he had the first episode of pneumococcal mitral valve endocarditis. He received pneumococcal vaccination two years ago. On examination during this admission, he was found to be febrile (104.3 F) and confused and had a grade 2/6 systolic murmur at the apex without any radiation. Laboratory data was significant for a white blood cell count of 22,000/mm3 (normal: 4000–11000/mm3). Blood cultures (4/4 bottles) grew penicillin-sensitive Streptococcus pneumoniae. Transesophageal echocardiogram revealed small vegetation on the posterior mitral leaflet without any evidence of abscess and severe mitral regurgitation. Patient clinically responded to intravenous ceftriaxone. However, due to recurrent pneumococcal mitral valve endocarditis and severe mitral regurgitation, the patient underwent mitral valve replacement. Patient had an uneventful recovery and was discharged home. Pneumococcal endocarditis itself is being uncommon in this current, penicillin, era; our case highlights the recurrent nature of pneumococcal endocarditis in a splenectomized host and the importance of pursuing aggressive treatment options in this clinical scenario.

Autoimmune Pancreatitis: A Diagnostic Challenge for the Clinician.

Abstract Autoimmune pancreatitis (AIP) is a rare cause of chronic pancreatitis that poses a diagnostic challenge to the clinician in that it mimics pancreatic cancer and presents with painless obstructive jaundice. In this review, we discuss the two types of AIP: type 1, known as lymphoplasmacytic sclerosing pancreatitis and type 2, known as idiopathic duct centric pancreatitis. Type 1 AIP is considered as a pancreatic manifestation of immunoglobulin G4-related disease. The etiopathogenesis of AIP, particularly type 2 AIP, is largely unknown. Both types of AIP have unique pancreatic histological features; however, the radiological and clinical features may mimic those of pancreatic cancer. The most commonly used diagnostic criteria, including the Japan Pancreas Society criteria, the Mayo Clinic HISORt (histology, imaging serology, other organ involvement, and response to therapy) criteria, and the International Association of Pancreatology’s international consensus diagnostic criteria, that help to differentiate AIP from pancreatic cancer are reviewed in this article. The treatment of choice for induction of remission for AIP is steroid therapy. Relapses are more common in type 1 AIP. In selected patients, immunomodulators such as azathioprine and rituximab are used to maintain remission.

Taking an Alternate Route Home: Stenting of Choledochoduodenal Fistula

A 53-year-old male with adenocarcinoma of the rectum with metastasis to liver and porta hepatis region underwent biliary stenting due to aggressive distal common bile duct stricture. At the time of planned stent exchange, the guidewire could not be re-introduced, despite several techniques, including the SpyScope® system. A small fistula was noted by contrast fluoroscopy extending between proximal biliary tree/porta hepatis and the duodenal bulb, likely secondary to previous chemotherapy and radiation. A stent was placed in this fistula, as this was the only pathway available for biliary drainage.

Case of colonic mucosal Schwann cell hamartoma and review of literature on unusual colonic polyps

Mucosal Schwann cell hamartomas (MSCH) are benign mesenchymal tumours rarely seen in the gastrointestinal tract. They occasionally present as incidental sessile polyps during colonoscopy. A 55-year-old asymptomatic female patient with a medical history of multiple sclerosis presented for a screening colonoscopy. A 5 mm low-risk tubular adenoma was noted in the caecum, and a second 5 mm polyp was found in the ascending colon. Histopathology of the ascending colon polyp showed proliferation of spindle cells without ganglion cells in the lamina propria. Immunohistochemical findings are compatible with an MSCH. Surveillance colonoscopy was scheduled in 5 years based on the presence of a single low-risk tubular adenoma.

Predictors of 30-Day Mortality in Hospitalized Patients with Clostridium difficile Infection

Objectives Clostridium difficile infection (CDI) is a significant cause of morbidity and mortality and is the most common nosocomial infection in the United States, with associated annual costs of approximately

Transient marked elevation of serum CA 19-9 levels in a patient with acute cholangitis and biliary stent.

3 billion. The epidemiology of CDI has changed with the identification of novel risk factors for incident and recurrent CDI. The aim of this study was to identify the predictors of 30-day mortality in hospitalized patients with CDI. Methods We identified all of the patients diagnosed as having CDI from January 2011 to December 2014 at our university-setting hospital. Data were extracted using electronic medical records and chart review. The data of all of the patients who died within 30 days of incident CDI were compared with those who survived beyond 30 days of incident CDI. A multivariable logistic regression model was created for mortality after finding a subset of significant predictor variables by making bivariate comparisons also using logistic regression. Results A total of 893 patients were diagnosed as having CDI during the study period. The mean age was 62 years and 49.5% were women. The mean length of hospital stay was 11.73 days. Of the 893 patients with CDI, 98 (10.97%) died within 30 days of incident CDI. CDI recurrence was noted in 76 patients (8.51%). On multivariate logistic regression analysis, peptic ulcer disease, advanced age, Charlson comorbidity index, and intensive care unit status were found to be significantly associated with 30-day mortality. There was no significant association between acid suppression and CDI mortality. Conclusions Advanced age, Charlson comorbidity index, intensive care unit status, and peptic ulcer disease are predictors of all-cause 30-day mortality in hospitalized patients with CDI.