Holy Foley: Iatrogenic Duodenal Obstruction From a Make-Shift Gastrostomy Tube

Introduction: Enteral feeding is a physiologic process of providing adequate nutrition and has been shown to improve both mortality and quality of life in patients with inadequate oral intake. Improved critical care medicine and recent wave of Coronavirus Disease 2019 (COVID-19) has left us with a large proportion of patients needing alternative enteral nutrition. Although rare, intussusception is an important differential for patients presenting with acute abdominal pain post makeshift percutaneous endoscopic gastrostomy (PEG) tube placement. Case Description/Methods: A 58-year-old male was admitted to the hospital for coffee ground emesis over three days accompanied with epigastric pain. He had right sided hemiparesis secondary to cerebrovascular accident with PEG tube for enteral nutrition. Examination was significant for epigastric tenderness with normal bowel sounds. PEG tube aspiration revealed bile-tinged fluid. Significant labs included white blood cell count of 11,600 /mm3, hemoglobin 10.2 g/dL, and lactic acid of 2.3 mmol/L. A computerized tomography of the abdomen with IV contrast showed a small segment duodeno-duodenal intussusception at the horizontal segment around the distal end of the tube was noted (Figure A). An urgent esophagogastroduodenoscopy (EGD) revealed a Foley catheter acting as a makeshift PEG tube extending across the pylorus into the duodenum. The distal tip of the Foley catheter was visualized with an inflated balloon seen in the third portion of the duodenum (Figure B) The inflated catheter balloon acted as a lead point causing intussusception in a ball-valve effect. The balloon was deflated, and the catheter was replaced (Figure C) with a 20 Fr PEG tube. Discussion(s): Gastric outlet obstruction is an uncommon complication reported in few cases caused by migration of the gastrostomy tube. Rarely this migrating gastrostomy tube can invaginate the duodenum or the jejunum causing intussusception. Only handful of cases have been reported in the literature. Patients usually present with epigastric pain, vomiting or rarely hematemesis. CT scan of the abdomen is the investigation of choice. Amidst the pandemic and supply shortage, Foley catheters have been deemed as a viable alternative to gastrostomy tubes and are being used more often. It is important to recognize this rare complication and use of balloon catheter should raise further suspicion. Timely endoscopic intervention can help avoid bowel necrosis and surgical intervention.

Management of Acquired von Willebrand Syndrome During Prolonged VV-ECMO

Acquired von Willebrand syndrome (AVWS) contributes to bleeding during extracorporeal membrane oxygenation (ECMO) support. Although it is recognized that AVWS rapidly resolves after ECMO decannulation, this approach may often be clinically unsuitable. In such cases, optimal AVWS management during ECMO support is not well established. We report our approach to managing AVWS in a patient on veno-venous (VV) ECMO for 59 days. A 19-year-old male developed hypoxemic respiratory failure from SARS-CoV-2 pneumonia. Following intubation, he progressed to VV-ECMO support for refractory hypoxemia and was started on bivalirudin for systemic anticoagulation. Two days later, he developed refractory gastrointestinal and oro-nasopharyngeal bleeding despite blood product transfusions and discontinuing bivalirudin. He was started on pantoprazole along with infusions of octreotide and aminocaproic acid. Upper endoscopy on ECMO day 5 revealed an ulcerative bleeding vessel in the duodenum that was clipped. Recurrent mucosal bleeding precluded resumption of systemic anticoagulation. On ECMO day 23, AVWS was diagnosed based on elevated von Willebrand factor (VWF) activity (207%, normal 55-189%) and antigen (234%, normal 50-210%) levels with abnormally low VWF high-molecular-weight multimers. Factor VIII complex was administered twice over the following week. Between doses, the ECMO circuit was exchanged to empirically mitigate suspected shear-related VWF consumption from the fibrin burden, and a repeat endoscopy controlled additional intestinal bleeding with local hemostatic agents. He received 36 units of red blood cells, 2 units of platelets, 2 units of plasma, and 7 pooled units of cryoprecipitate over 31 days leading into these combined interventions. In the 28 days afterwards, he received 3 units of red blood cells, 3.5 pooled units of cryoprecipitate, and no additional platelets or plasma. Our patient was maintained off systemic anticoagulation for 54 of 59 days of VV-ECMO support without any thrombotic complications occurring. With no subsequent clinical evidence of bleeding, repeat VWF testing was done two months post-decannulation and showed near-normal VWF activity (54%) and normal multimer distribution. Our patient rehabilitated well without any neurologic deficits and on discharge was requiring supplemental oxygen with sleep and strenuous activity. Avoiding systemic anticoagulation, repleting VWF, maintaining circuit integrity, and providing local hemostasis, when possible, may be a safe and effective management strategy of AVWS on ECMO support when decannulation is not a viable option.

Molecular genetics and genomics of the ABO blood group system

The A and B oligosaccharide antigens of the ABO blood group system are produced from the common precursor, H substance, by enzymatic reactions catalyzed by A and B glycosyltransferases (AT and BT) encoded by functional A and B alleles at the ABO genetic locus, respectively. In 1990, my research team cloned human A, B, and O allelic cDNAs. We then demonstrated this central dogma of ABO and opened a new era of molecular genetics. We identified four amino acid substitutions between AT and BT and inactivating mutations in the O alleles, clarifying the allelic basis of ABO. We became the first to achieve successful ABO genotyping, discriminating between AA and AO genotypes and between BB and BO, which was impossible using immunohematological/serological methods. We also identified mutations in several subgroup alleles and also in the cis-AB and B(A) alleles that specify the expression of the A and B antigens by single alleles. Later, other scientists interested in the ABO system characterized many additional ABO alleles. However, the situation has changed drastically in the last decade, due to rapid advances in next-generation sequencing (NGS) technology, which has allowed the sequencing of several thousand genes and even the entire genome in individual experiments. Genome sequencing has revealed not only the exome but also transcription/translation regulatory elements. RNA sequencing determines which genes and spliced transcripts are expressed. Because more than 500,000 human genomes have been sequenced and deposited in sequence databases, bioinformaticians can retrieve and analyze this data without generating it. Now, in this era of genomics, we can harness the vast sequence information to unravel the molecular mechanisms responsible for important biological phenomena associated with the ABO polymorphism. Two examples are presented in this review: the delineation of the ABO gene evolution in a variety of species and the association of single nucleotide variant (SNV) sites in the ABO gene with diseases and biological parameters through genome-wide association studies (GWAS).Copyright © Annals of Blood. All rights reserved.

IgM Multiple Myeloma Presenting With Diarrhea

Introduction: IgM Multiple Myeloma (MM) is a rare subtype of MM consisting of <1% cases of MM. It is distinguished from Waldenstrom Macroglobinemia, which also produces IgM, by the absence of somatic mutation MYD88. We present a patient with a chief complaint of diarrhea which unknowingly led to his hematological diagnosis Case Description/Methods: A 64 year old male with RA-SLE overlap syndrome on steroids, and recent COVID19 pneumonia, had presented with 5 episodes of watery diarrhea every day and 40 Ib weight loss within 2 months. CT revealed small bowel enteritis and stool studies, including C. diff, cultures, ova and parasites were negative. Diarrhea persisted despite antibiotics, therefore an EGD and Colonoscopy were performed which showed duodenal lymphangiectasia and a normal colon. Duodenal biopsy revealed eosinophilic deposits in the villous lamina propria which stained for IgM and stained negative under congo red ruling out amyloidosis. SPEP and a bone marrow biopsy revealed monoclonal IgMspikes and plasma cells in the bone marrow suggesting MMalong with a co-existing population of CLL. Next-generation sequencing was negative forMYD88, supporting IgM MM instead of Waldenstrom. He developed a protein-losing enteropathy with dramatic hypoalbuminemia (albumin 0.9) and lower extremity edema and DVTs. He was started on chemotherapy and frequent albumin infusions. His diarrhea completely resolved, however not in time, as his other medical comorbidities lagged behind and he developed anasarca and continued to deteriorate. Discussion(s): Plasma cell dyscrasias such as IgM MM or more commonly Waldenstrom have rarely been reported to cause GI symptoms. GI involvement can include direct GI infiltration of plasma cells, IgM deposition, or the finding of a plasmacytoma. It has been speculated that IgM deposits can lead to interstitial viscosity and obstructive lymphangiectasia leading to diarrhea and a protein-losing enteropathy as in our patient. Protein loss has led him to have hypoalbuminemia and possibly loss of antithrombotic proteins that have caused DVTs. Few case reports have suggested that treating the underlying cause with chemotherapy stops diarrhea entirely. Although our patient's diarrhea ceased, we believe that it was not in time for him to entirely recover from the later complications of the disease. We hope that this case can help clinicians to attempt prompt treatment of patients when they find GI specimens showing IgM deposits and they suspect a plasma cell dyscrasia.

Cholelithiasis Causing Asymptomatic Cholecystoenteric Fistula

Introduction: Biliary fistulas are a rare complication of gallstones. Fistula formation can occur in a number of adjacent sites;even more rare complication is the formation of a cholecystocolonic fistula. Case Description/Methods: A 74-year-old man who had recently undergone an extensive hospitalization secondary to inflammatory demyelinating polyneuropathy (IDP) and COVID-19 infection. During his hospitalization, he required ICU admission and mechanical ventilation with subsequent PEG tube placement. He was discharged to an inpatient rehabilitation facility when he developed worsening respiratory distress. Laboratory examinations were pertinent for ALT of 252, AST of 140 and ALP of 401 without hyperbilirubinemia. Blood cultures revealed Escherichia coli bacteremia. Given transaminitis and bacteremia, an MRCP was performed which demonstrated evidence absent space between gallbladder and hepatic flexure of the colon suggesting a CCF (Figure A). An ERCP with sphincterotomy was performed which showed extravasation of contrast from the gallbladder into the colon at the hepatic flexure (Figure B). He underwent cholecystectomy and fistula repair without any complications and gradual improvement in liver function test. He was discharged to a rehabilitation facility. Discussion(s): Complications of gallstones are well established, which include the common bile duct obstruction, but also include the rare occurrences of acute cholangitis, malignancy, and fistula formation. CCF is a rare complication of gallstones which can occur in the stomach, duodenum, or colon with a variable clinical presentation. Complications from an undiagnosed fistula can be life threatening including colon perforation and fecal peritonitis. This case highlights the diagnostic challenge and the high degree of clinical suspicion involved in establishing the diagnosis of CCF in patient without abdominal symptoms suggestive of gallbladder disease. We hypothesize that stone formation resulting in the development of the fistula may be secondary to the underlying history of IDP and subsequent immobility. Although rare, CCF should be considered in patients presenting with unexplained pneumobilia and bacteremia. A timely diagnosis should be made to proceed with immediate treatment including cholecystectomy and fistula closure to prevent fatal complications.

A Rare Cause of Enteritis in an Adult Male

Introduction: IgA vasculitis is more commonly seen in the pediatric population than in adults. Rarely IgA vasculitis is associated with malignancy, most commonly solid tumor malignancies, although there are case reports of association with hematologic malignancies. We report a case of large B-cell lymphoma mimicking IgA vasculitis in a 33-year-old immunosuppressed male with a prior history of IgA vasculitis. Case Description/Methods: A 33-year-old Caucasian male post renal transplant from reflux nephropathy on chronic immunosuppression was hospitalized for postprandial epigastric abdominal pain, nausea, vomiting and diarrhea. Two years prior, he was admitted for the same symptoms, palpable purpura of the lower extremities and elevated serum IgA. Enteroscopy had shown duodenal and jejunal ulceration with biopsies staining positive for IgA, confirming IgA vasculitis. He had complete resolution with a steroid taper. His current presentation had resulted in multiple hospital admissions, but empiric trial of steroids failed to alleviate symptoms. Vitals were normal and exam was notable for epigastric tenderness. Labs were notable for WBC 19.00 x103/cmm with normal differential, hemoglobin 9.2 gm/dL (prior 11.0 gm/dL), CRP 20.7 mg/L, serum creatinine 2.7 mg/dL (prior 1.5 mg/dL), and urinalysis with proteinuria, sterile pyuria, and hematuria. CTA abdomen/pelvis revealed thickening of the duodenum with shotty mesenteric lymph nodes without ischemia. Enteroscopy revealed an erythematous duodenum and jejunum (figure A). Jejunal biopsy (figure B) revealed CD20 positive cells consistent with DLCBL (figure C). He was seen by oncology and treated with R-CHOP but later unfortunately expired due to COVID-19 complications. Discussion(s): Non small cell lung cancer and renal cell carcinoma are most commonly associated with IgA vasculitis. It may also be seen in both Hodgkin and Non-Hodgkin lymphomas in adult patients. If IgA vasculitis occurs after a malignancy is diagnosed, it may indicate that metastasis has occurred. Malignancy associated IgA vasculitis is more likely to have an incomplete response to steroids and requires treatment of the underlying malignancy to achieve remission. Our case illustrates posterior probability error and premature closure cognitive biases. We should consider alternative diagnoses rather than anchor on prior diagnoses even when presentations are similar. Our case also highlights the importance of considering occult malignancy in adults with diagnosis of IgA vasculitis.

Medicinal bismuth: Bismuth-organic frameworks as pharmaceutically privileged compounds

Historically organometallic compounds have been used to cure certain diseases with limited applications. Although bismuth belongs to the category of heavy metals, many of its derivatives have found applications in modern drug discovery research, mainly because of its low toxicity and higher bioavailability. Being an eco-friendly mild Lewis acid, compounds having bismuth as a central atom are capable of binding several proteins in humans and other species. Bismuth complexes demonstrated antibacterial potential in syphilis, diarrhea, gastritis, and colitis. Apart from antibacterial activities, bismuth compounds exhibited anticancer, antileishmanial, and some extent of antifungal and other medicinal properties. This article discusses major synthetic methods and pharmacological potentials of bismuth complexes exhibiting in vitro activity to significant clinical performance in a systematic and timely manner.Copyright © 2022 Elsevier Ltd

Emergency surgical strategies for patients with acute abdomen during the COVID-19 outbreak.

Objective: To investigate the emergency surgical strategies for patients with acute abdomen during the Corona Virus Disease 2019 (COVID-19) outbreak. Method(s): The retrospective and descriptive study was conducted. The clinical data of 20 patients with acute abdomen who were admitted to the Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between January 18, 2020 and February 10, 2020 were collected. There were 13 males and 7 females, aged from 25 to 82 years, with an average age of 57 years. All the patients with emergency surgeries received pulmonary computed tomography (CT) examination before surgery, and completed nucleic acid detection in throat swab if necessary. Patients excluded from COVID-19 underwent regular anesthesia, suspected and confirmed cases were selected a proper anesthesia based on their medical condition and surgical procedure. Patients excluded from COVID-19 underwent emergency surgeries following the regular procedure, suspected and confirmed cases underwent emergency surgeries following the three-grade protection. Observation indicators: (1) surgical situations;(2) postoperative situations. Measurement data with normal distribution were represented as average (range). Count data were described as absolute numbers. Result(s): (1) Surgical situations: of the 20 patients with acute abdomen, 16 patients were excluded from COVID-19, and 4 were not excluded. All the 20 patients underwent emergency abdominal surgeries successfully, of whom 2 received surgeries under epidural anesthesia (including 1 with open appendectomy, 1 with open repair of duodenal bulbar perforation), 18 received surgeries under general anesthesia (including 9 with laparoscopic repair of duodenal bulbar perforation, 3 with open partial enterectomy, 3 with laparoscopic appendectomy, 1 with laparoscopic left hemicolectomy, 1 with laparoscopic right hemicolectomy, 1 with cholecystostomy). The operation time of patients was 32-194 minutes, with an average time of 85 minutes. The volume of intraoperative blood loss was 50-400 mL, with an average volume of 68 mL. (2) Postoperative situations: 16 patients excluded from COVID-19 preopratively were treated in the private general ward postoperatively. One of the 16 patients had fever at the postoperative 5th day and was highly suspected of COVID-19 after an emergency follow-up of pulmonary CT showing multiple ground-glass changes in the lungs. The patient was promptly transferred to the isolation ward for treatment, and results of nucleic acid detection in throat swab showed double positive. Medical history described by the patient showed that the patient and family members were residents of Wuhan who were not isolated at home during the epidemic. There was no way to confirm whether they had a history of exposure to patients with COVID-19. Medical staffs involved in this case did not show COVID-19 related symptoms during 14 days of medical observation. The other 15 patients recovered well postoperatively. The 4 patients who were not excluded from COVID-19 preoperatively based on medical history and results of pulmonary CT examination were directly transferred to the isolation ward for treatment postoperatively. They were excluded from COVID-19 for two consecutive negative results of nucleic acid detection in the throat swab and recovered well. Two of the 20 patients with acute abdomen had postoperative complications. One had surgical incision infection and recovered after secondary closure following opening incision, sterilizing and dressing, the other one had intestinal leakage and was improved after conservative treatment by abdominal drainage. There was no death in the 20 patients with acute abdomen. Conclusion(s): Patients with acute abdomen need to be screened through emergency forward. Patients excluded from COVID-19 undergo emergency surgeries following the regular procedure, and patients not excluded from COVID-19 undergo emergency surgeries following the three-grade protection. The temperature, blood routine test and other l boratory examinations are performed to monitor patients after operation, and the pulmonary CT and throat nucleic acid tests should be conducted if necessary. Patients excluded from COVID-19 preopratively are treated in the private general ward postoperatively, and they should be promptly transferred to the isolation ward for treatment after being confirmed. Patients who are not excluded from COVID-19 preoperatively based on medical history should be directly transferred to the isolation ward for treatment postoperatively.Copyright © 2020 by the Chinese Medical Association.

Emergency surgical strategies for patients with acute abdomen during the COVID-19 outbreak.

Objective: To investigate the emergency surgical strategies for patients with acute abdomen during the Corona Virus Disease 2019 (COVID-19) outbreak. Method(s): The retrospective and descriptive study was conducted. The clinical data of 20 patients with acute abdomen who were admitted to the Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology between January 18, 2020 and February 10, 2020 were collected. There were 13 males and 7 females, aged from 25 to 82 years, with an average age of 57 years. All the patients with emergency surgeries received pulmonary computed tomography (CT) examination before surgery, and completed nucleic acid detection in throat swab if necessary. Patients excluded from COVID-19 underwent regular anesthesia, suspected and confirmed cases were selected a proper anesthesia based on their medical condition and surgical procedure. Patients excluded from COVID-19 underwent emergency surgeries following the regular procedure, suspected and confirmed cases underwent emergency surgeries following the three-grade protection. Observation indicators: (1) surgical situations;(2) postoperative situations. Measurement data with normal distribution were represented as average (range). Count data were described as absolute numbers. Result(s): (1) Surgical situations: of the 20 patients with acute abdomen, 16 patients were excluded from COVID-19, and 4 were not excluded. All the 20 patients underwent emergency abdominal surgeries successfully, of whom 2 received surgeries under epidural anesthesia (including 1 with open appendectomy, 1 with open repair of duodenal bulbar perforation), 18 received surgeries under general anesthesia (including 9 with laparoscopic repair of duodenal bulbar perforation, 3 with open partial enterectomy, 3 with laparoscopic appendectomy, 1 with laparoscopic left hemicolectomy, 1 with laparoscopic right hemicolectomy, 1 with cholecystostomy). The operation time of patients was 32-194 minutes, with an average time of 85 minutes. The volume of intraoperative blood loss was 50-400 mL, with an average volume of 68 mL. (2) Postoperative situations: 16 patients excluded from COVID-19 preopratively were treated in the private general ward postoperatively. One of the 16 patients had fever at the postoperative 5th day and was highly suspected of COVID-19 after an emergency follow-up of pulmonary CT showing multiple ground-glass changes in the lungs. The patient was promptly transferred to the isolation ward for treatment, and results of nucleic acid detection in throat swab showed double positive. Medical history described by the patient showed that the patient and family members were residents of Wuhan who were not isolated at home during the epidemic. There was no way to confirm whether they had a history of exposure to patients with COVID-19. Medical staffs involved in this case did not show COVID-19 related symptoms during 14 days of medical observation. The other 15 patients recovered well postoperatively. The 4 patients who were not excluded from COVID-19 preoperatively based on medical history and results of pulmonary CT examination were directly transferred to the isolation ward for treatment postoperatively. They were excluded from COVID-19 for two consecutive negative results of nucleic acid detection in the throat swab and recovered well. Two of the 20 patients with acute abdomen had postoperative complications. One had surgical incision infection and recovered after secondary closure following opening incision, sterilizing and dressing, the other one had intestinal leakage and was improved after conservative treatment by abdominal drainage. There was no death in the 20 patients with acute abdomen. Conclusion(s): Patients with acute abdomen need to be screened through emergency forward. Patients excluded from COVID-19 undergo emergency surgeries following the regular procedure, and patients not excluded from COVID-19 undergo emergency surgeries following the three-grade protection. The temperature, blood routine test and other l boratory examinations are performed to monitor patients after operation, and the pulmonary CT and throat nucleic acid tests should be conducted if necessary. Patients excluded from COVID-19 preopratively are treated in the private general ward postoperatively, and they should be promptly transferred to the isolation ward for treatment after being confirmed. Patients who are not excluded from COVID-19 preoperatively based on medical history should be directly transferred to the isolation ward for treatment postoperatively.Copyright © 2020 by the Chinese Medical Association.

A Study of Perforative Peritonitis in a Period of One Year during Covid-19 Pandemic at a Medical College in Rajasthan

Hollow viscous perforation is one of the most common emergency dealt by general surgeons worldwide. A high degree of suspicion is required and prompt management is warranted to reduce morbidity and mortality. Here we present a study of perforative peritonitis in our medical college at the outskirt of Udaipur city in the state of Rajasthan, India during the Covid-19 pandemic. During the one year study period from September 2020 to August 2021, a total of 16 cases of hollow viscous perforation admitted and treated. The number is relatively low because of the pandemic and there was a period of total lockdown with negligible patient footfall. All patient had free gas under diaphragm in plain x-ray and all of them were scheduled for emergency laparotomy after adequate resuscitation. Emphasis given on the location of perforation, etiology, organism on culture of peritoneal fluid and procedure undertaken. Copyright © 2022, Dr Yashwant Research Labs Pvt Ltd. All rights reserved.

Uptake of No- Biopsy Approach in Diagnosing Paediatric Coeliac Disease in a Regional Tertiary Centre

Background Coeliac disease (CD) is an immune mediated systemic disorder strongly associated with HLA DQ2 and DQ8 haplotypes.2 In 2012 The European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) recommended serology based No-Biopsy Approach to the diagnosis of CD if I - Perifollicular Petechiae the following criteria are met1: Design/Methods A 6-year retrospective study of all children who attended coeliac clinic at The Great North Children Hospital, Newcastle. Data obtained using electronic patient records included TGA-IgA, EMA-IgA, symptoms at initial presentation and histopathological reports. HLA typing results were obtained from the Regional NHS blood and transplant laboratory. 346 children with CD were reviewed in the coeliac clinic from July 2013 to July 2019. Age range 0.9 - 16.5 years (median 9.5 years) and 54% female. Exclusion criteria include diagnosed outside study period or the UK, TGA-IgA at initial presentation unavailable for review. Results 66% of cases had TGA-IgA >=10xULN at initial presentation. 48% were diagnosed by serology based No-Biopsy Approach (figure1). Duodenal biopsies were performed in 82 cases. Biopsies were performed for type1 diabetes -8.5% and asymptomatic patients with first-degree relative with CD -8.5% (figure 1). EMA-IgA positivity was reported in 65/68 cases with symptoms attributed to CD in 62 cases in the cohort. A total of 13/62 cases had HLA risk alleles DQ2 and/or DQ8 performed (figure 2). Conclusion(s)*HLA screening uptake was 63%. The low uptake of HLA typing may have contributed to the increased number of cases undergoing duodenal biopsies.*Based on 2012 guidelines 19% of cases had duodenal biopsies for diagnosis of CD despite meeting the criteria for no biopsy approach.*Based on 2020 guidelines 96% of cases had duodenal biopsies for diagnosis of CD despite meeting the criteria for no biopsy approach.*The changes in the CD guidelines from 2012 to 2020 have resulted in an increase from 16% to 96% of cases that may have benefitted from no biopsy approach to the diagnosis of CD.*A unifying approach to the diagnosis of the CD will reduce the variability in investigations.*The current restrictions to Aerosol Generating Procedures due to SARS-CoV -2 pandemic will have a positive impact on establishing a No-Biopsy approach to the diagnosis of CD.

TULAREMIA PRESENTING AS LARGE GI ULCERATION AND HEMORRHAGE

SESSION TITLE: Critical Care Infections SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Francisella tularensis is a zoonotic disease by an aerobic, gram negative coccobacillus. It is transmitted by exposure to infected animal or vectors in individuals who landscape or camp. Common symptoms are fever, chills, anorexia, and headache. Abdominal tularemia can present with abdominal pain, emesis, diarrhea, and rarely intestinal ulceration and hemorrhage. It is treated with aminoglycosides, fluoroquinolones and tetracycline. CASE PRESENTATION: 38-year-old male presented with fever, cough, anorexia, and black stool for 5 days. Patient worked as a landscaper. He has no pets, travel history or sick contacts. He does not take any medications at home. Physical exam was significant for sinus tachycardia and rhonchi of right upper lobe. Significant labs include WBC of 9.8 with 41% bands, hemoglobin 15.5, sodium 125, procalcitonin 27.3, and lactic acid 1.8. COVID-19, MRSA, Legionella and Pneumococcal urine antigen were negative. CTA chest revealed mass-like opacity in right upper lobe with multiple bilateral pulmonary nodules. Lower respiratory culture showed Candida albicans. Patient was empirically started on ceftriaxone and azithromycin. He was transferred to intensive care for worsening respiratory status and was placed on non-invasive ventilation on hospital day 1. Antibiotics were broadened to ceftaroline and levofloxacin due to suspicion of tularemia. Amphotericin B was added. Labs for Histoplasma, Blastomyces, TB, Leptospira, and HIV were negative. Patient then suffered a cardiac arrest on hospital day 2 after having large brown secretions pouring from his mouth. Cardiopulmonary resuscitation was initiated and patient was intubated and started on vasopressors with return of spontaneous circulation. Massive blood transfusion protocol was initiated. Emergent bedside upper endoscopy showed large blood clot adherent to duodenal ulcer. Interventional radiology planned on performing gastric duodenal artery embolization. However, patient suffered two more cardiac arrest with resuscitation efforts terminated per family request. Karius Digital Culture later was positive for Francisella tularensis. Autopsy revealed diffuse alveolar hemorrhage, hilar lymphadenopathy, and perforated duodenal ulceration with large adherent clot. DISCUSSION: Gastrointestinal tularemia is rare and usually from drinking contaminated water or oral inoculation of bacteria. Intestinal tract involvement can present with mesenteric lymphadenopathy and ulcerative lesions resulting in gastrointestinal bleeding with case fatality rate of 50%. Even though this is noted in the literature, to our knowledge no case reports have been published. CONCLUSIONS: Careful history taking and early identification of risk factors are important when severe tularemia infection is suspected such as in individuals with extensive outdoor activities. Treatment should be empirically initiated in high risk patients. Reference #1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4585636/ Reference #2: https://casereports.bmj.com/content/2017/bcr-2017-22125. Reference #3: Altman GB, Wachs JE. Tularemia: A pathogen in nature and a biological weapon. Aaohn Journal. 2002 Aug;50(8):373-9. DISCLOSURES: No relevant relationships by Maria Haider Baig

Identification of Persistent Sars-Ncov-2 Viral Presence in the Intestines of Multiple Pediatric Patients Suggests Possible Common Etiology of Gi Long Covid

Background: The phenomenon known as "Long Covid," (LC) marked by post-infectious symptoms of a wide variety, and typically not associated with initial infectious severity, has the potential to become a tremendous public health burden as infections continue at a high rate. Variations of LC may impact over 80% of patients, with unclear pathogenesis, although many speculate that persistent viral presence in end-organ tissue may drive local changes. We previously published a case report noting persistent SARS-nCoV-2 activity in the cecum of a patient 3 months after initial infection (Arostegui et al, JPGN Reports, 2022). We have sought to expand that finding by assessing additional patients who have undergone endoscopic evaluation for presence of SARS-nCoV-2 nucleocapsid, seeking to expand our understanding of the clinical effects of persistent infection. Method(s): We identified 6 patients with onset of symptoms in the post-SARS-nCoV-2 window, who had undergone EGD/colonoscopy without histopathological diagnosis. New blank slides were cut and sent for staining at Histowiz inc (Brooklyn, NY), with rabbit monoclonal SARS-CoV-2 nucleocapsid antibody (GTX635686, 1:10,000). Resulting slides underwent blinded pathology review to identify positives. Chart review was completed on patients who were identified as positive, including histopathology data from endoscopy, medical history, presentation, laboratory results and clinical course. Result(s): Including our initial report, we have identified 4 female patients ages 11-16 to date. Viral presence was identified in the duodenum and TI, but only in one patient in the colon (cecum). Patients presented for evaluation of a variety of GI manifestations including chronic abdominal pain (100%), nausea and vomiting (50%), loss of appetite (50%), tenesmus (50%), hematochezia (25%) as well as weight loss (50%). Notably, of the 4 patients identified, only 1 had a known history of confirmed SARS-nCoV-2 infection. Endoscopic findings in the intestine were normal with the exception of edema noted in the cecum of two patients. Mucosal biopsies were also positive for notable (if typically felt to be non-pathologic) lymphoid aggregates in the Colon (75%) as well as in the Terminal Ileum (50%). Clinical information is summarized in Table 1. Conclusion(s): Additional identification of persistent SARS-nCoV-2 presence in patients ranging from 3-18 months after symptom onset demonstrates a high likelihood that persistent viral presence contributes to post-infectious symptoms in many patients. Patients demonstrated "red flag" symptoms like nighttime awakening with pain, weight loss, and elevated inflammatory markers or calprotectin, but symptomatically improved over time and with measures targeted at IBS. Our limited sample size prevents determination of typical location of persistent viral activity, but it is notable that symptoms for colonic vs. SI persistence were clinically consistent, with diarrhea in colonic persistence and early satiety/pain characterizing SI persistence. Most notably, we have identified a tendency for persistent infection to occur, potentially explaining at least a subset of persistent IBS-like symptoms associated with GI LC. Further work is necessary to determine exactly the prevalence of this issue, as well as to characterize the natural history of the clinical course, and possible effective therapies. (Table Presented).

Rare atypical presentation of a polymicrobial gastropericardial fistula.

We present the unique case of a gastropericardial fistula with a rare, delayed presentation in a man in his 70s. Relevant surgeries include Watchman Left Atrial Appendage Closure device placement 1 year prior to arrival and gastric bypass surgery 20 years prior to arrival. The patient presented to the emergency department with weakness, diarrhoea and left knee pain. He was admitted for cellulitis of the left lower extremity, prosthetic septic arthritis of the left knee and group G streptococcus bacteraemia. His hospital course was complicated by acute chest pain and dyspnoea. Imaging revealed pneumopericardium. Oesophagogastroduodenoscopy visualisation confirmed the diagnosis of gastropericardial fistula. The patient could not be transferred to a tertiary centre for definitive management because of the effect of the COVID-19 pandemic on tertiary hospital volumes. After pericardial drainage and administration of antimicrobials without improvement, the patient was discharged to hospice care at his request and died 1 day after discharge.

A phase 1b study of blinatumomab with the anti-programmed cell death (PD)-1 antibody AMG 404 in adults with relapsed/refractory (R/R) B-cell precursor acute lymphoblastic leukemia (ALL)

Background: Preclinical data indicate that anti-PD-1 agents can facilitate activity of bispecific T-cell engager (BiTE) molecules. Here we assess the combination of the anti-CD19 BiTE molecule blinatumomab with the anti-PD-1 antibody AMG 404 in adults with R/R ALL (NCT04524455). Methods: Eligible adults with R/R ALL (Ph+ disease included) received 2-5 treatment cycles. Each cycle was 42 days, consisting of 4 weeks of cIV blinatumomab and a 2-week treatment-free interval as per label. In Cohort 1, AMG 404 was dosed IV at 240 mg every 4 weeks (Q4W);first dose was Day (D) 11 of Cycle (C) 1. Primary endpoints were dose-limiting toxicities (DLTs) and other adverse events (AEs). Results: As of 20 Dec 2021, patients (pts) from Cohort 1 (n=8) had median age of 57 (range: 24-73) y, 6/ 8 male, 6/8 Caucasian, 1 with extramedullary disease (duodenum), 2 with prior blinatumomab, and a median of 5 (2-15) prior treatment lines. Two pts remain on study and 2 completed the study;4 pts discontinued the study due to death (n=3) or consent withdrawn (n=1). No DLTs were reported for the 3 evaluable pts. Of the 5 pts not evaluable for DLTs, in C1, 4 had disease progression and 1 an unrelated fatal pneumonia. Treatment-related grade (Gr) ≥3 and/or serious AEs in all 8 pts included cytokine release syndrome (CRS) (1 pt Gr 2, 1 pt Gr 1 and 3), Gr 3 increases in ALT and AST, Gr 3 fever, Gr 3-4 neutropenia, Gr 4 neutropenia/Gr 3-4 thrombocytopenia (same pt), Gr 2 sensorimotor polyneuropathy, Gr 3 hypertension, Gr 3 encephalopathy, and in 1 pt Gr 3-4 decreases in white blood cells, lymphocytes, and neutrophils. One pt developed Gr 3 SARS-COV-2 pneumonia on C2D25, resolving without clinical sequelae. C3 start was delayed by 12 days but protocol treatment resumed uneventfully. All 3 DLT-evaluable pts had a complete response (CR) or CR with partial hematologic recovery (CRh), 2/3 without measurable residual disease (MRD), within 2 cycles;the 3rd pt had an MRD response at the end of C3. Preliminary pharmacokinetic results for the combination of blinatumomab and AMG 404 demonstrated that their exposures were consistent with those observed for each as monotherapy and did not indicate any drug-drug interactions. To date, all samples tested for anti-blinatumomab antibodies have been negative. Conclusions: In this ongoing phase 1b study, the combination of blinatumomab with AMG 404 was tolerated with a manageable safety profile. No DLTs were reported. Enrollment continues in Cohort 2 in which AMG 404 is dosed Q4W at 480 mg starting on C1D1, 48 hours prior to blinatumomab.

Lightning strikes thrice

Introduction: A case of multiple co-existing conditions during pregnancy in a previously fit and well individual. Case Report: A 24-year-old woman presented at 37 weeks during her second pregnancy with a five day history of vomiting and abdominal pain. She had no significant past medical history. Her oxygen saturations were low so she received treatment for aspiration pneumonia. Her initial COVID-19 antigen test was negative however subsequent PCR was positive. The cause of her acute abdomen was unclear, with the differentials being perforated duodenal ulcer, pancreatitis and appendicitis. With input from general surgery, obstetrics and anaesthesia a decision was made to proceed with a diagnostic laparotomy. Classical caesarean section was performed at the beginning of the procedure. A healthy baby was delivered and laparotomy revealed pancreatitis. Due to high intraoperative oxygen requirements, shewas kept intubated and transferred to intensive care post operatively. An echocardiogram revealed biventricular failure and she was commenced on treatment for peripartum cardiomyopathy. Overall, she remained intubated for nine days andwas discharged from hospital 16 days following her surgery. Followup echocardiogram four months after hospital discharge showed her left ventricular ejection fraction remained <35%. Discussion: COVID-19 is increasingly common these days so it is likely to co-exist with other conditions. The incidence of acute pancreatitis during pregnancy is approximately one in 3000 and the incidence of peripartum cardiomyopathy is also approximately one in 3000 in the western world [1,2]. This case serves as a reminder that multiple conditions may be present in one individual and highlights the importance of completing a full set of investigations. This patient had multiple reasons for respiratory failure, however, an echocardiogram was necessary to reveal peripartum cardiomyopathy. Her ejection fraction remains low which puts her at high risk of mortality for future pregnancies. However, this diagnosis has allowed her to receive the appropriate follow up and counselling.

LOCAL AND SYSTEMIC ADVERSE REACTIONS FOLLOWING COVID-19 VACCINE

The mass vaccination against novel coronavirus infection (COVID-19) requires to dynamically evaluate risks of adverse events following immunization to prevent them and develop vaccination tactics for various population groups. We describe a clinical case of reaction following administration of the second dose of the heterologous recombinant adenovirus based COVID-19 vaccine Gam-COVID-Vac (Sputnik V) in 48-year-old female healthcare worker. No adverse events after administration of the first dose were recorded. After vaccination, the patient complained of weakness, malaise, headache, loss of appetite, and nausea that lasted for a single day. Reaction at the injection site appeared 10 hours after vaccination manifested as pruritic erythema, induration area up to 1.5 cm size, sharp pain, which resolved within 24 hours. On the second day post-vaccination, an inflammation area up to 1.5 cm size within the Bacillus Calmette–Guérin (BCG) scar site was noted and manifested as erythema, induration, painful to palpate, pruritus located 2 cm away from the injection site. BCG scar reaction with dull pain and severe pruritus lasted for three weeks. Erythema and induration at the BCG scar site resolved two months after the onset, which were resolved by using antihistaminic agent. The patient was vaccinated according to the Russian Federation Immunization Program, not associated with any adverse events following immunization. The patient had comorbidities such as vasomotor rhinitis, urolithiasis, stomach, duodenal ulcer, type 2 diabetes, arterial hypertension, and her body mass index of 35.2. The patient permanently receives antihypertensive and antihyperglycemic drugs, and has allergic reaction in the form of urticaria to Berodual. The patient has menopause during two years, but a five-day postmenopausal bleeding three days after vaccination with the second dose was noted. Thus, a high-quality surveillance of any local and systemic reactions associated with vaccination is needed to reveal adverse events to the vaccines against COVID-19 and elaborate a safe immunization program for preventing COVID-19.

SARS-COV-2 IS DETECTED IN THE GASTROINTESTINAL TRACT OF ASYMPTOMATIC OUTPATIENTS USING ROUTINE ENDOSCOPY BUT POSES MINIMAL TRANSMISSION RISK

Objective: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been detected in multiple organ systems including the gastrointestinal (GI) tract using standard PCR techniques. However, whether the human gut supports active SARS-CoV-2 replication leading to shedding of infectious virions is still a matter of debate. Our study aimed to determine whether SARS-CoV-2 could be recovered from the GI tract of asymptomatic outpatients to assess the risk of SARS-CoV-2 exposure for healthcare workers performing routine endoscopies. Methods: Between April 2020 and February 2021, we enrolled 112 patients aged 19 – 70 years undergoing elective endoscopic procedures who had no known SARS-CoV-2 exposure or recent COVID-19 test result (n=100) or who had a history of previous SARS-CoV-2 infection but had recovered at the time of the procedure (n=12). None of the patients had gastrointestinal symptoms at the time of COVID-19 infection or respiratory complaints at the time of the endoscopy. Liquids and biopsies from the colon, ileum, duodenum, and stomach were collected during endoscopy following standard bowel preparation protocols. Samples were analyzed for SARS-CoV-2 by PCR, and PCR-positive samples were analyzed for the presence of infectious virus by VeroE6 plaque assays. We also used plaque assays to assess whether endoscopic colonic liquids could inactivate SARSCoV- 2. Results: Interestingly, one colonic biopsy out of the 255 tissue samples collected from patients with no known SARS-CoV-2 exposure tested positive for SARS-CoV-2 by PCR. Out of 12 patients who had recovered from COVID-19 between 2 and 21 weeks before the endoscopic procedure, three colonic fluid samples tested positive for SARS-CoV-2 (Fig. 1A). Positive PCR results were confirmed by an independent laboratory. Importantly, no replication-competent virus was detected in any of the tissue or liquid samples. In vitro treatment of SARS-CoV-2 with colonic liquid showed that SARS-CoV-2 was completely inactivated after 24 hours, but at 10 minutes and 1-hour viral inactivation varied considerably between samples (Fig. 1B). Discussion: In 25% (3 out of 12) of patients with previous COVID-19 history, virus was detected by PCR for up to 5 months following resolution of symptoms. Viral genomes were also detected in colonic biopsies from one subject with no known SARS-CoV-2 infection, consistent with a large proportion of asymptomatic infections in the US population. The persistent detection of SARS-CoV-2 genomes in endoscopy samples after resolution of COVID-19 points to the gut as a reservoir for SARS-CoV-2 and confirms previous reports of long-term SARS-CoV-2 shedding in fecal samples. However, the absence of infectious virions in the samples and the rapid inactivation of SARS-CoV-2 in colon liquids suggests that the risk to healthcare workers involved in endoscopy procedures is likely low. (Figure Presented)

2021 Owen H Wangensteen Scientific Forum of the American College of Surgeons

The proceedings contain 629 papers. The topics discussed include: barriers to Covid-19 vaccination in underserved minorities: impact of health care access and sociodemographic perspectives;concomitant cholecystectomy during initial bariatric surgery does not increase risk of postoperative complications or bile duct injuries;identifying behavioral facilitators to weight loss after bariatric surgery: are there differences between Medicaid and non-Medicaid patients?;impact of post-discharge phone calls on nonurgent hospital returns;laparoscopic heller myotomy is associated with fewer postoperative complications compared to the thoracoscopic approach: a NSQIP study;population-wide analysis of the effect of bariatric surgery on idiopathic intracranial hypertension in obese patients;reducing operating room inefficiencies via a novel surgical app shortens the duration of laparoscopic Roux-en-y gastric bypass;subtotal gastrectomy vs gastroenterostomy in duodenal obstruction secondary to peptic ulcer disease: results of a retrospective nationwide study;and enhanced recovery after bariatric surgery: further reduction in opioid use with the introduction of dexmedetomidine and transverse abdominis plane block.

Efficacy of Probiotic on Duodenal TNF-α Expression and the Histological Findings in the Liver and Lung in Animal Model Canine Coronavirus

Currently, Canine coronavirus (CCoV) is an enteric pathogen of the Alphacoronavirus-1 species that causes mild to severe diarrhea in puppies. The pathogenesis of this infection will cause severe lymphopenia and lead to death in puppies. This study aimed to determine the administration of probiotics on TNF-α expression, histological findings of the liver and lung in mice infected with CCoV. A total of 28 mice were randomly assigned into seven treatment groups, i.e. (C-) placebo;(C+) active CCoV vaccine induction;(T1) CCov + Isopronosin;(T2) CCoV + Lactobacillus acidophilus probiotic;(T3) CCoV + Lactobacillus Acidophylus and Bifidobacterium probiotics;(T4) CCoV + colustrum fermentation probiotic;(T5) CCoV + ginger, turmeric and ginger probiotics. Thereafter, the expression of TNF-α in the duodenum was stained using immunohistochemistry, liver and lung were stained using hematoxylin eosin. The data were analyzed using the ANOVA test followed by the Tukey test with a significance level (p<0.05). TNF-α expression on T4 and T5 decreased significantly (p<0.05) compared to C+, T1, T2 and T3. Histologic findings of the liver in the C- and T4 groups showed normal features in the central vein. On the other hand, glycogen accumulation was found in hepatocyte cells, hemorrhage with sinusoid dilation, lymphocyte infiltration in centro lobular area in group C+. Lung histology showed normal features of sinusoids and alveolar septa in groups C- and T4. Meanwhile, intra-alveolar hemorrhage was found with neutrophil cell infiltration and fibrin plasma accumulation in group C+. In conclusion, colostrum fermentation probiotics can reduce TNF-α expression in the duodenum and improve the liver and lung physiology in mice infected with CCoV.