Joshua Aron

Nephrotic syndrome after treatment of Crohn's disease with mesalamine: Case report and literature review

Inflammatory bowel disease and its various treatments may affect the kidney in several ways. Recently, case reports have been published documenting the development of nephrotic syndrome after the treatment for inflammatory bowel disease with 5-aminosalicylic acid derivatives. We report a 50-year-old patient who was diagnosed with Crohns disease and was treated with mesalamine. The patient subsequently developed nephrotic syndrome and a renal biopsy showed minimal change disease. He was treated with losartan and rosuvastatin and showed improvement in his renal function and serum cholesterol level. This is the first reported case in Crohns disease although there have been six previous case reports of nephrotic syndrome following salicylic acid derivatives for ulcerative colitis.

Su2012 A First Case Report of Colorectal Cancer Associated With Chronic Strongyloides Stercoralis Colitis and the Complex Management Decisions That Follow

Rarely pathogenic organisms including parasites can act as carcinogens. To our knowledge, there are no reported cases regarding the association between a Strogyloides stercoralis infection and colon cancer. A 47 year old Columbian man with Vitiligo presented to our Emergency Room with fatigue, 25 lb weight loss in 6 months and iron deficiency anemia. He denied diarrhea or blood per rectum and there was no personal or family history of malignancy, celiac or IBD. On admission, the physical exam was notable for vitiligo and a positive guaiac. The hemoglobinwas 3.1 gm/dL and 26.4% eosinophilia was seen. Endomysial Ab, ESR, and CRP were all normal. 5 units of PRBCs were transfused. The patient had a normal EGD and colonoscopy 6 yrs prior for the workup of anemia, but there were no records available to review. Both EGD and colonoscopy were then performed at our institution. The EGD was grossly normal and biopsies of the duodenum were obtained to exclude occult celiac. The colonoscopy, however, demonstrated a severe right sided colitis, with friable granular mucosa, erosions and confluent loss of vascular markings and haustral folds. In addition, a 3cm ulcerated mass was identified in the colitic ascending colon and biopsies confirmed invasive low grade adenocarcinoma. Of interest, the ileal and rectosigmoid mucosa appeared grossly normal. No metastasis were identified on abdominal and chest CT and the surgeons scheduled a total colectomy for presumptive IBD associated dysplasia. The stool studies and duodenal biopsies returned positive for Strongyloides stercoralis. Treatment was initiated with 2 doses of Ivermectin 200mcg/kg/d. At tumor board, the pattern of a colitis secondary to Strongyloides rather than IBD was emphasized with the consensus for an extended right hemicolectomy with ileocolic anastomosis. Intraoperatively the left colon appeared grossly normal, surgical staging confirmed a T3N0M0 tumor, stage 2b. Given the concerns for hypereosinophilic syndrome with immunosuppressive therapies, fecal confirmation of strongyloides eradication was confirmed 12 weeks postop. Adjuvant chemotherapy was offered but the patient declined after explanation of the risks and benefits. To date, the patient remains asymptomatic and surveillance colonoscopies at 6 months and 2 yrs have demonstrated no evidence of gross colitis or dysplasia, reaffirming the infectious etiology. This case illustrates the only known association of chronic colitis and colon cancer due to Strongyloides stercoralis. In atypical chronic colitis, and in populations at risk for Stronyloidiasis, it is essential to exclude this parasite prior to potentially life threatening immunosuppression that one would choose to treat IBD. However, dysplasia surveillance should also be considered given the potential for malignancy as demonstrated in this patient with strongyloides chronic colitis.

Knowing what's out there: awareness of non-alcoholic fatty liver disease

Background: Non-alcoholic fatty liver disease (NAFLD) is the most common hepatic disorder, which poses a significant health burden in the western countries. As the epidemic of obesity slides health downward, the incidence of NAFLD is evidently increasing. Aim: We aimed to ascertain the awareness of NAFLD and its risk factors in the general population, which may be helpful in designing educational tools to promote prevention, early detection, and treatment of this disorder. Methods: A survey of 5000 non-institutionalized residents of Brooklyn, NY, USA was conducted. Sixteen items were included in the survey questionnaire including awareness of fatty liver, predisposing factors of NAFLD, awareness of cirrhosis, and conditions that advance to cirrhosis. The questionnaire also addressed awareness of prevention, diagnostic methods and treatment of NAFLD, and education of physicians to their patients about NAFLD. Results: Overwhelming majority of the subjects was not aware of NAFLD and stated that their physicians did not have a discussion about NAFLD. Conclusion: Non-alcoholic fatty liver disease is a preventable liver disorder with limited treatment options. Thorough counseling by primary care physicians can be of paramount importance in preventive strategy for NAFLD. We should target our teenage population in an era of obesity epidemics of all times.

Small Bowel Amyloidosis

Purpose of ReviewThe goal of this paper is to review the literature on small bowel amyloidosis. Our review focuses on the underlying etiology, histopathology, clinical features, endoscopic and radiologic findings, and the mainstay of management.Recent FindingsThe latest research shows changing epidemiological trends of different types of amyloidosis. It also reveals a better understanding of its pathophysiology and shows improvement in treatment outcomes.SummaryAmyloidosis is a group of diseases of multiple etiologies and clinical presentations. It is characterized by pathological deposition of insoluble fibrillar proteins within various organs leading to disruption of their structure and function. The classification of amyloidosis includes primary, secondary, dialysis-related, senile, and hereditary. Amyloidosis can be systemic or localized. The incidence of AA amyloidosis is declining in frequency. If the gastrointestinal (GI) tract is involved, the small intestine is the most commonly affected site. Overall, outcomes among patients with newly diagnosed amyloidosis have improved. This article focuses on small bowel amyloidosis.

Acute hepatitis E presenting with clinical feature of autoimmune hepatitis

A 32-year-old immigrant man presented with new onset jaundice. His past medical history was significant for type 2 diabetes mellitus, hypertension, and hyperlipidemia. His initial laboratory finding and liver biopsy were suggestive of autoimmune hepatitis (AIH). The plan was to start steroids pending negative results for viral serology, but it came back positive for hepatitis E virus. The patients liver function test and clinical condition improved significantly on conservative management over a period of 1 month. Therefore, we suggest testing for hepatitis E especially in immigrants or recent travelers to endemic areas who presents with clinical features suggestive of AIH.

Erythema Elevatum Diutinum

CASE PRESENTATION A50-year-old man presented with painful nodular lesions of the hand and elbow (Figure A). Laboratory findings revealed high serum immunoglobulin A level of 2,290 mg/dL and positive hepatitis C antibody with high viral load. Biopsy revealed lamellar fibrosis and preponderance of neutrophils with leukocytoclasts and histiocytes (Figure B) and the patient was diagnosed with erythema elevatum diutinum (EED). EED is a rare and distinctive form of chronic cutaneous leukocytoclastic vasculitis belonging to the group of the neutrophilic dermatoses. The lesions manifest as symmetrical, firm, yellow or pinkish to red, purple or brown papules, plaques or nodules on the backs of the hands, feet and extensor surfaces of the extremities overlying joints. EED can occur in any age, but it is most common in the third to sixth decade. Extracutaneous symptoms may include arthralgia, constitutional symptoms and occular abnormalities. The exact

Primary squamous cell carcinoma of the rectum: a case report and literature review.

Squamous cell carcinoma (SCC) of the rectum is a rare occurrence with an incidence rate of 0.1–0.25% per 1,000 cases. Herein, we report a case of a 52-year-old female who presented with a 2-month history of diffuse lower abdominal pain and hematochezia. Abdominal CT scan revealed a 7-cm irregular rectal mass, and the biopsy showed SCC.

Colorectal Cancer Associated with Strongyloides stercoralis Colitis

Strongyloides stercoralis colitis is a severe but easily curable disease with a high mortality rate if left untreated. Strongyloidiasis can persist up to several decades and may lead to a chronic colitis similar to that seen in inflammatory bowel disease (IBD), and the two are often confused. Chronic colitis from IBD is associated with an increased risk of colorectal cancer, so it is plausible that chronic colitis from strongyloidiasis may carry a similar risk. Our case report associates chronic Strongyloides colitis and colorectal cancer.

Lung Abscess: Atypical Presentation of Achalasia.

CASE PRESENTATION A 31-year old man was admitted with a 5-day history of productive cough and night sweats along with 1-year history of intermittent reflux and dysphagia. On admission, patient was febrile with decreased breath sounds in the left upper lobe. Computerized tomography of the chest revealed an abscess in the left upper lobe and distended esophagus with air-fluid levels (Figure A arrows). Patient was ruled out for tuberculosis and started on antibiotics empirically for lung abscess deemed secondary to recurrent aspiration. Barium swallow revealed a dilated esophagus with eccentric tapering (Figure B). Upper endoscopy showed a dilated esophagus with food in the mid and distal esophagus. Rest of the examination was normal. Esophageal manometry confirmed the diagnosis of achalasia. Achalasia is a primary motility disorder of the esophagus. Both structural and functional changes in the lungs can be seen in patients with achalasia.

Acute Gastric Ischemia After Chemoembolization in a Patient with Hepatocellular Carcinoma

A 72-year-old man presented with severe diffuse abdominal pain and melena. His past history was significant for hepatitis C cirrhosis and hepatocellular carcinoma status post partial resection five years ago and recurrent malignant lesions treated with multiple sessions of transarterial chemoembolization (TACE). He had received his last TACE treatment of a lesion in segment 6 via a distal branch of the right renal artery 2.5 months prior to the presentation. His examination was significant for moderate abdominal distension and tenderness. Laboratory findings were notable for the following: hemoglobin, 7.4 g/dl; creatinine, 2.4 mg/dl; and lactate, 10.1 mmol/l. Initial computerized tomography of the abdomen/pelvis without contrast showed cirrhosis and a hepatic mass, a markedly distended stomach, and gas in the gastric wall, an intrahepatic portion of the portal vein, and the gastric veins (a). Esophagogastroduodenoscopy showed ulceration and necrosis localized to the fundus and proximal lesser curvature (b). The patient was managed conservatively with bowel rest, intermittent nasogastric tube suction, intravenous (IV) fluids, IV pantoprazole, and broad-spectrum antibiotics. He responded well to medical management, showing marked improvement on repeat imaging with contrast (c). (Informed consent was obtained from the patient to publish these images.)