Omar N Nadhem

Review and practice guidelines for celiac disease in 2014

Abstract Celiac disease, or gluten-sensitive enteropathy, is defined as a state of heightened immunologic responsiveness to ingested gluten (from wheat, barley, or rye) in genetically susceptible individuals. Ingestion of the offending proteins leads to inflammation and intestinal mucosal damage, which may result in a spectrum of gastrointestinal symptoms, nutritional abnormalities, and systemic complications ranging from anemia and osteoporosis to secondary autoimmunity and malignancy. The genetic influence in the pathogenesis of celiac disease is indicated by its familial occurrence. Celiac disease does not develop unless a person has alleles that encode for human leukocyte antigen DQ2 or DQ8 proteins. The clinical picture of celiac disease has changed considerably during the past 30 years. Diarrhea, which was the presenting symptom in > 90% of celiac disease patients before 1981, is now the chief complaint in < 40%. In contrast, the increased frequency of atypical celiac disease presentations, including anemia and bone disease, is revealed by the widespread availability of serologic testing. An association between celiac disease and autoimmune disorders, such as type 1 diabetes, autoimmune thyroid disease, and Sjögren’s syndrome, has been well documented. The tissue transglutaminase immunoglobulin antibody and the endomysial immunoglobulin antibody are the most sensitive and specific serologic tests, respectively, for identifying individuals who need to undergo an intestinal biopsy. If the suspicion of celiac disease is high, intestinal biopsy should be pursued even if serologic tests are negative. The gold standard for the diagnosis of celiac disease is a small bowel biopsy showing villous atrophy. The treatment for celiac disease is lifelong adherence to a gluten-free diet (GFD). Despite the proven benefits of the GFD, it can be exceedingly difficult to completely avoid gluten-containing foods, and adherence to a GFD is estimated to be only 45% to 80%.

Diabetic Ketoacidosis as First Presentation of Latent Autoimmune Diabetes in Adult

A 54-year-old white female with hypothyroidism presented with abdominal pain, nausea, vomiting, and diarrhea. She was found to have diabetic ketoacidosis (DKA) and admitted to our hospital for treatment. Laboratory workup revealed positive antiglutamic acid decarboxylase antibodies and subsequently she was diagnosed with latent onset autoimmune diabetes in adult (LADA). She was successfully treated with insulin with clinical and laboratory improvement. Diagnosis of LADA has been based on three criteria as given by The Immunology of Diabetes Society: (1) adult age of onset (>30 years of age); (2) presence of at least one circulating autoantibody (GADA/ICA/IAA/IA-2); and (3) initial insulin independence for the first six months. The importance of this case is the unlikely presentation of LADA. We believe that more research is needed to determine the exact proportion of LADA patients who first present with DKA, since similar cases have only been seen in case reports. Adult patients who are obese and have high blood sugar may deserve screening for LADA, especially in the presence of other autoimmune diseases. Those patients once diagnosed with LADA need extensive diabetic education including potentially serious events such as diabetic ketoacidosis.

Autoimmune Hepatitis with Multiple Sclerosis and Graves Disease: Coincidence or Association

Autoimmune hepatitis (AIH) is a generally progressive, chronic hepatitis of unknown cause that occurs in children and adults of all ages. It is associated with a variety of autoimmune conditions like thyroid disorders (Hashimoto and Graves disease), celiac disease and multiple sclerosis (MS). We report the case of a 61-year-old woman with MS (untreated) and a history of Graves disease who presented with fatigue and right upper quadrant abdominal pain. She was admitted to our hospital for evaluation. Clinical and laboratory workup revealed AIH. She was successfully treated with prednisone and azathioprine, with complete clinical and laboratory improvement. However, to our knowledge there have been only a few reports of a possible association between AIH and untreated MS.

A 47-Year-Old Stem Cell Transplant Recipient with Fever, Cough and Chest Pain

Infections and malignancies are among the most serious complications that follow organ or stem cell transplantation. They may have a mild course, and nonspecific and overlapping manifestations. The present article describes a case of symptomatic nodular pulmonary disease that complicated hematopoietic stem cell transplantation. It was diagnosed to be post-transplant lymphoproliferative disorder, a potential sequela of immunosuppression and a very difficult entity to treat in profoundly immunosuppressed patients.

Acute Gastric Volvulus and Atrial Fibrillation with RVR: A Coincidence or Association

Gastric volvulus is a rare and life-threatening condition that involves the abnormal rotation of the stomach around its axis by more than 180°. The association between acute gastric volvulus and atrial fibrillation with rapid ventricular response is rare with only few cases that have been reported. Our patient was an 86-year-old female who presented with upper abdominal pain, distension, nausea, and shortness of breath. Clinical and laboratory workup revealed acute gastric volvulus with diaphragmatic hernia. On presentation, she was also in atrial fibrillation with rapid ventricular response. She was successfully treated by laparotomy with reduction of the gastric volvulus and repair of the diaphragmatic hernia, with significant improvement.

Acute Pancreatitis: An Atypical Presentation

Acute pancreatitis is an important cause of acute upper abdominal pain. Because its clinical features are similar to a number of other acute illnesses, it is difficult to make a diagnosis only on the basis of symptoms and signs. The diagnosis of acute pancreatitis is based on 2 of the following 3 criteria: (1) abdominal pain consistent with pancreatitis, (2) serum lipase and/or amylase ≥3 times the upper limit of normal, and (3) characteristic findings from abdominal imaging. The sensitivity and specificity of lipase in diagnosing acute pancreatitis are undisputed. However, normal lipase level should not exclude a pancreatitis diagnosis. In patients with atypical pancreatitis presentation, imaging is needed. We experienced two cases of acute pancreatitis associated with normal serum enzyme levels. Both patients were diagnosed based on clinical and radiological evidence. They were successfully treated with intravenous fluids and analgesics with clinical and laboratory improvement. The importance of this case series is the unlikely presentation of acute pancreatitis. We believe that more research is needed to determine the exact proportion of acute pancreatitis patients who first present with normal serum lipase, since similar cases have been seen in case reports.

Right-sided Pleuritic Chest Pain in a 36-year-old Male.

A 36-year-old male was admitted with right-sided pleuritic chest pain that had lasted five days. There was no fever or chills, but he reported shortness of breath and long-standing coughing and wheezing. The cough was intermittently productive of brown sputum. The patient was diagnosed with bronchial asthma 10 years prior. He was managed by a pulmonologist until he lost his job and insurance three years before his presentation to the hospital. In those three years he continued to treat himself with 20 to 60mg prednisone daily to control his coughing and wheezing. His medical history was otherwise unremarkable. He was married with two healthy sons, and he had no history of smoking. On examination, the patient was thin and in mild respiratory distress. Vital signs were as follows: temperature 37.6oC, heart rate 104beats/min (regular), blood pressure 127/76mmHg, respiratory rate 28breaths/min, and oxygen saturation 94% while on 2L/min of oxygen via a nasal cannula. Significant physical examination findings included the following: right-sided pleural rub and shallow inspirations, regular heart sounds without murmurs or gallop, and no lymphadenopathy or rash. Pertinent laboratory findings included the following: white blood cells count 12,200/μL (79% neutrophils and 15% lymphocytes), hemoglobin level 11.8g/dL, platelet count 276,000/μL, and human immunodeficiency virus (HIV) test was negative. Liver enzymes, kidney function tests, and coagulation studies were within normal limits. Chest X-ray (CXR) on admission and computed tomography (CT) scan are shown in Figures 1 and 2. Figure 1 Chest X-ray on admission of a 36-year-old male with right-sided pleuritic chest pain. Figure 2 Computed tomography scan cross-section on admission. The patient underwent CT guided biopsy and histopathology [Figures 3 and 4]. Figure 3 Hematoxylin and eosin stained lung biopsy, magnification=200×. Figure 4 Gomori methenamine silver stained lung biopsy, magnification=200×.

The yield of stool testing in hospital-onset diarrhea: Has evidence changed practice?

Abstract Introduction: Aside from examination for Clostridium difficile, the yield of stool testing in hospital-onset diarrhea is poor. Clinical practice guidelines discourage overzealous stool testing in patients with diarrhea that develops after the third hospital day. However, the adoption of this recommendation into clinical practice is limited. Furthermore, the effect of microbiology laboratory improvements on hospital-onset diarrhea testing is largely unknown. Methods: A retrospective cohort study was conducted in a university-affiliated community-hospital and included all adult inpatients who developed diarrhea after hospitalization. Results: 132 adult patients (53% female) developed diarrhea after hospitalization in 2013. The cohort’s mean age was 55.6 years. 46.2% of patients developed diarrhea in the first 3 days of hospitalization. Testing for parasites was negative in all examined 67 samples. Testing for C. difficile was positive in 13 cases (10.8%) out of 120 tested samples. Testing for other pathogens was positive in 1 sample (Campylobacter) out of 129 samples. Stool samples tested in the first 3 days of hospitalization were more likely to be positive (64.3 vs 35.7%, p = 0.1). Change in management was reported in 9 out of 14 patients (64.3%) with positive stool testing compared with 31 out of 118 patients (26.3%) with negative stool testing, p = 0.01. Conclusion: Despite improvements in stool samples’ testing, the yield continues to be low, especially in hospital-onset diarrhea past the third hospital day. Physicians’ embracement of the ‘3-day rule’ continues to be poor.

A 71-year-old woman with recurrent falls and confusion

Case presentation A 71-year-old African-American woman presented to the authors’ hospital with recurrent falls and confusion. She reported fatigue, loss of appetite and weight loss that had been progressing over several months. In the two days before her presentation, she felt dizzy and the family noticed intermittent confusion. She denied fever, respiratory or urinary symptoms. She reported chronic constipation but no abdominal pain or vomiting. Her medical history was significant for rheumatoid arthritis (RA) and hypertension. The patient’s RA had never been treated, despite disease progression over the years; meanwhile, her hypertension was well controlled on hydrochlorothiazide and amlodipine. The patient denied smoking, alcohol abuse or illicit drug use. She also denied any recent medical procedures or dental work. On examination, she was afebrile, with a temperature of 37.4°C and a blood pressure of 96/58 mmHg. Her heart rate was 92 beats/min and her oxygen saturation was 94% on room air. She was cachectic with no lymphadenopathy. She was edentulous with no gum line swelling or tenderness. Her skin was intact, with no bruising or rashes. She had clear lung fields, regular heart sounds without murmurs and soft abdomen with no organomegaly. She had obvious chronic joint deformities related to her RA. Her neurological examination was nonfocal. Laboratory test results revealed a hemoglobin level of 98 g/L and white blood cell count of 10.6×109 cells/L. Chemistry tests showed a creatinine level of 106.1 μmol/L and albumin level of 19.0 g/L; alkaline phosphatase, total bilirubin and liver transaminase levels were normal. Computed tomography scans of the brain were negative. Urinalysis and chest x-ray were negative. The anaerobic bottles of the blood culture sets obtained on admission were observed to be positive after 24 h. The Gram stain of the positive bottles is shown in Figure 1. What is your diagnosis?

A 55-year-Old Male Immigrant with Lymphoma and Gram-Negative Sepsis

1Department of Internal Medicine; 2Section of Infectious Diseases, Department of internal medicine, Texas Tech University Health Sciences Center, Amarillo, Texas, USA Correspondence: Dr Faisal A Khasawneh, Section of Infectious Diseases, Department of Internal Medicine, Texas Tech University Health Sciences Center, 1400 South Coulter Street, Amarillo, Texas 79106, USA. Telephone 806-690-7074, fax 806-354-5765, e-mail faisal.khasawneh@ttuhsc.edu CASE PRESENTATION A 55-year-old male immigrant from Iraq presented with progressive shortness of breath and hypotension. The illness started with diarrhea and headache, and began three weeks after the first cycle of chemotherapy (cyclophosphamide, doxorubicin, vincristine and prednisone) was administered for the patient’s newly diagnosed lymphoma. On presentation, he was in septic shock and respiratory failure requiring mechanical ventilation. The patient had altered sensorium and neck rigidity. He had no rashes and no lymphadenopathy. His white blood cell count was 16.9×109 cells/L with 8% eosinophilia. Chemistry tests showed acute kidney injury with a creatinine level of 168.0 μmol/L. Chest x-ray showed multilobar pneumonia. His blood and sputum cultures grew Escherichia coli. Lumbar puncture performed 24 h after presentation showed pleocytosis and elevated protein level; however, the culture was negative. A diagnostic test was performed. What is your diagnosis?