Whipple's disease unmasked by TNF inhibitor therapy for treatment of seronegative rheumatoid arthritis.

We report a patient with seronegative rheumatoid arthritis diagnosed with Whipple's disease following treatment of tumour necrosis factor inhibitor (TNFI) therapy. Whipple's disease should be considered in patients with seronegative rheumatoid arthritis and other unexplained multisystem illness. The TNFI therapy and immunosuppressive therapies can unmask latent Whipple's disease.

Lactobacillus rhamnosus sepsis, endocarditis and septic emboli in a patient with ulcerative colitis taking probiotics.

A man in his 60s presented to the emergency room with fever and fatigue after a 2.5-month course of corticosteroids. His medical history was significant for bioprosthetic aortic valve replacement and moderately severe ulcerative colitis treated with balsalazide and daily lactobacillus-containing probiotics. Initial investigations revealed Lactobacillus rhamnosus bacteraemia without complication. Four days after hospital discharge, the patient experienced acute-onset right-sided paraesthesia and lower-limb paresis. On return to the emergency room, MRI of the brain demonstrated innumerable ring-enhancing lesions with haemorrhagic transformation. Transoesophageal echocardiogram revealed a small mobile density on the bioprosthetic aortic valve, raising the suspicion for L. rhamnosus infective endocarditis with secondary septic emboli to the brain. The patient was subsequently treated with intravenous gentamycin and ampicillin, with transition to indefinite oral amoxicillin suppressive therapy. The current case highlights the potential risk of lactobacilli translocation in an immunosuppressed patient with ulcerative colitis taking probiotics.

Acquired long QT syndrome due to antiemetics, COVID-19 and Blastocystis hominis induced exacerbation of congenital chloride losing diarrhoea.

Congenital chloride losing diarrhoea (CCLD) is a rare disease caused by mutations in an intestinal chloride/bicarbonate ion exchange channel. Few reports describe CCLD in adults and none has described the impact of a parasitic infection on CCLD. Severe diarrhoea may result in hypokalaemia with QT interval prolongation. Treatment with antiemetics may further increase the QT interval. To raise awareness of this preventable complication, we describe the course of a woman in her 20s with CCLD who developed COVID-19 and a Blastocystis hominis infestation. Treatment with antiemetics and hypokalaemia resulted in prolongation of the QT interval to 640 ms. While, the QT interval normalised with discontinuation of antiemetics and electrolyte replacement, patients with CCLD must take precautions to prevent gastrointestinal infections. Regardless, whenever patients with CCLD present to hospital, the authors recommend monitoring the QT interval and avoiding medications that predispose to torsade de pointes.

Co-infection of intestinal tuberculosis and mucormycosis in a patient with Down syndrome: a unique case report with literature review.

Mucormycosis represents several unusual opportunistic infection caused by saprophytic aseptate fungi. There is a recent rise in cases of mucormycosis due to an increase in diabetic and immunodeficient patients like patients on long-term steroids, immunomodulators due to organ transplantation, malignancies, mainly haematological malignancies, and autoimmunity. Anatomically, mucormycosis can be localised most commonly as rhino-orbito-cerebral followed by pulmonary, disseminated, cutaneous and gastrointestinal, rarest being small intestinal. Patients with Down syndrome are immunodeficient due to their impaired immune response. Disseminated tuberculosis is also common in immunodeficient patients. We report a rare case of small intestinal mucormycosis in a patient with Down syndrome with coexisting intestinal tuberculosis. Due to the invasiveness of mucormycosis, the patient succumbed to death despite providing aggressive surgical debridement and medical management.

Fulminant necrotising amoebic colitis after corticosteroid therapy for severe COVID-19.

Acute fulminant necrotising colitis is an uncommon presentation of amoebiasis, which can be precipitated after corticosteroid therapy. Clinicians treating patients with COVID-19 with corticosteroid therapy should be familiar with this condition to avoid delay in diagnosis. The disease is associated with high mortality, and prompt diagnosis and management are essential for salvaging patients. We report successful management of a patient who developed this complication following administration of steroids for COVID-19.

SARS-CoV-2-triggered lymphocytic colitis.

The ability of SARS-CoV-2 to infect the gastrointestinal tract is well described. Inflammatory bowel diseases (IBD) are believed to represent a disorganised immune response in genetically predisposed individuals, which are triggered by various environmental factors, notably infections. Here we report a case of chronic watery diarrhoea that was triggered by a SARS-CoV-2 infection. The work-up confirmed a new diagnosis of lymphocytic colitis, and the patient responded favourably to a course of oral budesonide. Clinicians should become vigilant to the possibility of triggered IBD in patients with persistent diarrhoea following a SARS-CoV-2 infection.

Rare case of gastrointestinal mucormycosis with colonic perforation in an immunocompetent patient with COVID-19.

Primary gastrointestinal mucormycosis is a rare disease associated with an increased mortality and is rarely reported in an immunocompetent host. We report the first case of mucormycosis-associated colonic perforation in a COVID-19 patient with a favourable outcome. A 48-year-old healthy male doctor in home isolation due to COVID-19 was admitted to COVID-19 intensive care unit when his symptoms deteriorated. The patient was put on non-invasive ventilation (NIV) using Bilevel Positive Airway Pressure (BiPAP) and treatment given as per existing hospital protocol. The patient improved clinically, and was discharged on day 10 of admission. Two days later, he presented with acute gastrointestinal symptoms to the emergency department. A diagnosis of perforation peritonitis was made, the patient was stabilised and sigmoid colectomy with descending colon colostomy was done. A diagnosis of gastrointestinal mucormycosis was made and injectable antifungal was started. The patient was discharged after his general conditions improved.

Eosinophilic appendicitis due to Strongyloides stercoralis: a challenging differential diagnosis for clinicians.

A 45-year-old man presents with 48-hour status of high temperature, cough and dyspnoea. In the context of pandemic, the patient is initially diagnosed with COVID-19 syndrome. Later, the laboratory and ultrasound study supported acute appendicitis diagnosis. Appendicectomy was performed. The histopathology study confirmed eosinophilic appendicitis and that a parasitic infection was suspected. The stool sample was positive for Strongyloides stercoralis The diagnosis of a S stercoralis is a rare finding in Spain. S. stercoralis simulates clinical findings of inflammatory bowel disease or eosinophilic gastroenteritis, which may lead to the wrong therapeutic choice. Since in inflammatory diseases corticosteroid treatments are considered the initial choice in many cases, in the case of S. stercoralis infection, the administration of this therapy can be fatal. In Spain, the number of diagnoses is much lower than in the past decade, although it is highly probable that the infection has been underdiagnosed due to low clinical awareness among Spanish population.

Serrating through vascular access catheters: a great masquerader with severe systemic manifestations.

Serratia marcescens, time and again, has demonstrated its ability to easily adhere and infect vascular access catheters, making them a bona fide source of hospital outbreaks and contributing to adverse patient outcomes. We present a unique case of a severe recurrent Serratia infection, leading to persistent bacteria in the blood, haematogenous dissemination and subsequent development of abscesses, to a degree not reported in the literature before. These infections are exceedingly challenging to eradicate, owing to multiple virulence mechanisms and the deep seeding ability of this microorganism. Serratia infections require a multifaceted approach with intricacies in identification, therapeutics and surveillance, all of which are sparsely reported in the literature and reviewed in this report.

Good functional outcome following severe neutropenic enterocolitis and perforation in a 48-year-old woman undergoing chemotherapy for breast cancer.

Neutropenic enterocolitis (NEC) is a life-threatening bowel condition, usually resulting from chemotherapy, with a mortality rate thought to be as high as 50%. Markers of poor prognosis include gastrointestinal perforation and bowel wall thickness radiologically detected to be greater than 10 mm. NEC is associated with severe neutropenia and predominantly affects the large bowel; however, we present a case of severe NEC with oesophageal perforation requiring transfer to a specialist upper gastrointestinal unit for corrective stenting. Despite initial bowel wall thickness of 20 mm in the ascending colon, two discrete episodes of bowel perforation and an inpatient stay totalling 89 days, the patient was discharged with full independence, a good quality of life and a plan for curative mastectomy plus axillary clearance.

Atypical manifestations of COVID-19 in general practice: a case of gastrointestinal symptoms.

During the previous months, we have seen the rapid pandemic spread of SARS-CoV-2. Despite being considered a respiratory virus, it has become clear that other clinical presentations are possible and some of these are quite frequent. In this paper, a case of a man in his late 70s showing atypical symptoms in general practice is presented. Apart from fever, the patient complained of diarrhoea, borborygmus, loss of appetite and nausea. He developed no respiratory symptoms during his disease. Due to his symptoms, malignant disease was suspected, and he was referred for further testing which revealed typical COVID-19 findings on a chest CT scan. The occurrence of atypical symptoms is discussed, including the importance of recognising these in an ongoing pandemic.

COVID-19 presenting with diarrhoea and hyponatraemia.

COVID-19 is a viral disease with a high infectivity rate. The full spectrum of the disease is not yet understood. This understanding may help in limiting potential exposure. We present a young man with diarrhoea, abdominal pain and hyponatraemia who turned out to be positive for COVID-19.