IRF2BP2 mutation with autoimmune enteropathy, immune deficiency, and respiratory failure

Case history: We present the case of a 31-year-old Hispanic male with history of recurrent bronchiectasis, invasive aspergillosis, and severe persistent asthma, who is now status post lung transplant for end-stage lung disease. He initially presented at 7 years of age with diarrhea, failure to thrive, and nearly absent immunoglobulin levels (IgG < 33 mg/dL, IgA < 7 mg/dL, IgM = 11 mg/dL, IgE = 4 IU/dL) necessitating IVIG treatment. Small intestinal biopsy showed villous atrophy consistent with autoimmune enteropathy. Sweat chloride was reported as indeterminate (44 me/dL). Initial WBC, platelet, and T- and NK-cell counts were within normal range, and B-cell count and percentage were borderline low. Most recently, he was found to have increased immature B-cell count (CD21low), decreased memory B-cells, and poor pneumococcal vaccine antibody response. Patient has been hospitalized numerous times with increasingly severe bronchiectasis, pneumonitis, and COVID-19 infections twice despite vaccination, leading to respiratory failure and lung transplantation. Family history is negative for immune deficiency and lung diseases. Discussion(s): Of these 3 VUSs (see the table), the one in IRF2BP2 has the most pathogenic potential due to its autosomal dominant inheritance, its location in a conserved domain (Ring), and previous case reports of pathogenic variants at the same or adjacent alleles 1-3. Baxter et al reported a de novo truncating mutation in IRF2BP2 at codon 536 (c.1606CinsTTT), which is similar to our patient's mutation. This patient was noted to have an IPEX-like presentation, with chronic diarrhea, hypogammaglobulinemia, and recurrent infections. Variant Functional Prediction Score for our variant predicts a potentially high damage effect. There are 2 other case reports of heterozygous mutations in loci adjacent to this allele;one (c.1652G>A)2 with a similar clinical phenotype to our patient and the other (C.625-665 del)3 with primarily inflammatory features and few infections. Impact: This case highlights a variant in IRF2BP2 associated with severe hypogammaglobulinemia, recurrent pulmonary infections, and autoimmune enteropathy. [Table presented]Copyright © 2023 Elsevier Inc.

Surveillance for SARS-CoV-2 in Norway Rats (Rattus norvegicus) from Southern Ontario

The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from wildlife has raised concerns about spillover from humans to animals, the establishment of novel wildlife reservoirs, and the potential for future outbreaks caused by variants of wildlife origin. Norway rats (Rattus norvegicus) are abundant in urban areas and live in close proximity to humans, providing the opportunity for spillover of SARS-CoV-2. Evidence of SARS-CoV-2 infection and exposure has been reported in Norway rats. We investigated SARS-CoV-2 infection and exposure in Norway rats from Southern Ontario, Canada. From October 2019 to June 2021, 224 rats were submitted by collaborating pest control companies. The majority of samples were collected in Windsor (79.9%;n = 179), Hamilton (13.8%;n = 31), and the Greater Toronto Area (5.8%;n = 13). Overall, 50.0% (n = 112) were female and most rats were sexually mature (55.8%;n = 125). Notably, 202 samples were collected prior to the emergence of variants of concern (VOC) and 22 were collected while the Alpha variant (B.1.1.7) was the predominant circulating VOC in humans. Nasal turbinate (n = 164) and small intestinal (n = 213) tissue samples were analyzed for SARS-CoV-2 RNA by RT-PCR. Thoracic cavity fluid samples (n = 213) were tested for neutralizing antibodies using a surrogate virus neutralization test (sVNT) (GenScript cPass);confirmatory plaque reduction neutralization test (PRNT) was conducted on presumptive positive samples. We did not detect SARS-CoV-2 RNA in any samples tested. Two out of eleven samples positive on sVNT had neutralizing antibodies confirmed positive by PRNT (1 : 40 and 1 : 320 PRNT70);both were collected prior to the emergence of VOC. It is imperative that efforts to control and monitor SARS-CoV-2 include surveillance of rats and other relevant wildlife species as novel variants continue to emerge.

Whipple's Disease, An Overlooked Diagnosis

Whipple disease is a rare multisystem inflammatory disease. Because fewer than 1000 reported cases have been described, clinical experience with this disorder is sparse. We are reporting a case of a 46-year-old man who presented with fever, weight loss, and polyarthralgia for 2 months, and 1 month of diarrhea. The patient was thoroughly investigated for collagen diseases and COVID-19, with no definite diagnosis. A therapeutic trial by immunosuppressive drugs provided partial remission followed by a marked rebound of the symptoms. His occult blood in stool was positive and subsequent upper endoscopy with proximal small intestinal biopsies showed the pathological features of Whipple's disease. The patient showed a dramatic improvement following treatment with ceftriaxone and trimethoprim-sulfamethoxazole. Despite the rarity of Whipple's disease, its course mimics many rheumatological diseases, inflammatory bowel disease, and COVID-19 disease. It should always be a part of the differential diagnosis of obscure polyarthralgia and chronic diarrhea.Copyright © 2023 The Author(s).

Natural Evolution of Porcine Epidemic Diarrhea Viruses Isolated from Maternally Immunized Piglets

Simple SummaryDuring the long-term co-evolution of the virus and the host, even closely related vaccines may emerge with incomplete protective immunity due to the mutations or deletions of amino acids at specific antigenic sites. The mutation of PEDV was accelerated by the recombination of different strains and the mutation of the strains adapting to the environment. These mutations either cause immune escape from conventional vaccines or affect the virulence of the virus. Therefore, researching and developing new vaccines with cross-protection through continuous monitoring, isolation and sequencing are important to determine whether their genetic characteristics are changed and to evaluate the protective efficacy of current vaccines. The porcine epidemic diarrhea virus (PEDV) can cause severe piglet diarrhea or death in some herds. Genetic recombination and mutation facilitate the continuous evolution of the virus (PEDV), posing a great challenge for the prevention and control of porcine epidemic diarrhea (PED). Disease materials of piglets with PEDV vaccination failure in some areas of Shanxi, Henan and Hebei provinces of China were collected and examined to understand the prevalence and evolutionary characteristics of PEDV in these areas. Forty-seven suspicious disease materials from different litters on different farms were tested by multiplex PCR and screened by hematoxylin-eosin staining and immunohistochemistry. PEDV showed a positivity rate of 42.6%, infecting the small and large intestine and mesenteric lymph node tissues. The isolated strains infected Vero, PK-15 and Marc-145 multihost cells and exhibited low viral titers in all three cell types, as indicated by their growth kinetic curves. Possible putative recombination events in the isolates were identified by RDP4.0 software. Sequencing and phylogenetic analysis showed that compared with the classical vaccine strain, PEDV SX6 contains new insertion and mutations in the S region and belongs to genotype GIIa. Meanwhile, ORF3 has the complete amino acid sequence with aa80 mutated wild strains, compared to vaccine strains CV777, AJ1102, AJ1102-R and LW/L. These results will contribute to the development of new PEDV vaccines based on prevalent wild strains for the prevention and control of PED in China.

General Surgery Resident Case Numbers During the Covid-19 Pandemic

Introduction: The COVID-19 pandemic has had widespread effects on the healthcare system. For trainees, one particular detriment has been the cancellation of elective operations, reducing clinical experience and procedural volumes. Measures instituted to combat the pandemic have resulted in decreased cancellation of elective cases to varying degrees. The aim of this study is to evaluate the ongoing effect of the pandemic on resident operative volume. Method(s): Operative case numbers of general surgical graduates in 2019, 2020, and 2021 were extracted from the Accreditation Council for Graduate Medical Education case logs. Data included mean total cases/graduate and means for individual case types. Data was considered by overall number of cases and cases performed as surgeon chief. Analysis of variance was employed to compare groups with p<0.05 considered significant. Result(s): Mean total major cases differed significantly among groups with reduced volume noted for 2020 graduates but no difference in volume between 2019 and 2021 graduates (1070.5+/-150 vs 1054.8+/-155 vs 1074.1+/-164, p=0.0041). This same pattern was noted for surgeon chief total cases (288.6+/-69 vs 264.4+/-67 vs 286.2+/-73, p<0.0001) as well as several major general surgery subcategories including cases involving the stomach, small intestine, large intestine, biliary system, among others. Conclusion(s): Despite continued reduction in and alteration of elective surgery practice, improved pandemic measures have allowed for increased surgical volume. This has translated to increased operative experience for graduating surgical trainees that are comparable to case numbers that preceded the pandemic. Ramifications for the 2020 graduating cohort as well subsequent cohorts require continued evaluation.

Acute Pancreatitis Following a Lower Extremity Angioplasty

Introduction: Acute pancreatitis affects a significant population globally. Usual etiologies are gallstones, alcohol, hypertriglyceridemia, medications;less frequent are trauma, hypercalcemia, infections, toxins, ischemia, anatomic anomalies, vasculitis, and idiopathic. Pancreatitis post coronary intervention is an uncommon cause with only 19 published cases in the last two decades. Being cognizant of this etiology is important given the increasing number of patients undergoing angiography. Case Description/Methods: An 81-year-old female with hypertension, diabetes, peripheral arterial disease, prior cholecystectomy underwent left lower extremity angioplasty at an outside center. Within a few hours, she started having severe epigastric pain radiating to her back, nausea, vomiting and loose bloody stool. She presented to the emergency department 24 hours after symptom onset. Epigastric tenderness was present on exam. Labs revealed leukocytosis (24,450/muL), elevated lipase (1410 U/L), elevated creatinine (1.3 mg/dL), lactate (3.1 mmol/L), calcium 9.4 mg/dL and triglycerides 161 mg/dL. Incidentally, found to be positive for COVID-19. Normal common bile duct diameter seen on sonogram. CT angiogram of the abdomen/pelvis showed acute pancreatitis, duodenal and central small bowel enteritis (Figure). She was not on any medications known to cause pancreatitis and denied alcohol use. Patient improved with analgesics and intravenous fluids. She had no recurrence of bloody stools and hemoglobin remained stable. On day 4, she was able to tolerate a regular diet, and leukocyte count and creatinine normalized. Patient did not have any COVID respiratory symptoms, and was discharged. Discussion(s): Given the temporal association to angioplasty and no other identifiable cause, acute pancreatitis was presumed to be due to the contrast used during angioplasty. Other possibilities included cholesterol embolism but no peripheral signs of cholesterol embolism were seen. Patient was an asymptomatic COVID-19 case. Although, there are case series of pancreatitis due to COVID, those were found in very sick symptomatic patients. On review of literature, cholesterol embolism was identified as a definite cause only on autopsy or laparotomy (Table). Other possible mechanisms are: high viscosity of the contrast media leading to ischemia and necrosis, contrast causing NF-kB activation followed by epithelial damage, and vasospasm. Pancreatitis after coronary angiography is rare, nonetheless, an important differential especially if there is a temporal relationship.

Lactulose Works in the Large Bowel: But How Does It Improve Hepatic Encephalopathy in a Patient Without a Large Bowel?

Introduction: Lactulose is a non-absorbable disaccharide which acts in the large bowel, and is commonly used in the treatment of hepatic encephalopathy. We present an interesting case of altered mental status due to hepatic encephalopathy successfully managed with lactulose in a patient with history of total colectomy. Case Description/Methods: A 67-year-old male with non-alcoholic cirrhosis and inflammatory bowel disease (IBD) post total proctocolectomy with a continent ileostomy known as a Kock-pouch (K-pouch) presented to the hospital with flu like symptoms and altered mental status. He was subsequently found to be positive for COVID-19. At the time of initial evaluation, the patient was obtunded with an elevated ammonia level of 91 umol/L. Colorectal surgery was consulted as the patient was not able to empty his K-pouch. Recently, he complained of inability to catheterize and with bleeding from the stoma. Initial catheterization with a Water's tube yielded 400 cc of effluent. Nasogastric tube was placed through which he was receiving lactulose 30 mg q8 hours. The patient's mental status improved within 24 hours. The patient ultimately underwent flexible pouchoscopy with endoscopic dilation and placement of a 22 French mushroom catheter for decompression of the K-pouch. Discussion(s): Lactulose is a non-absorbable disaccharide composed of galactose and fructose. The small intestine does not have the enzymes required to breakdown lactulose so it reaches the large bowel in its original form. In the large bowel, it is metabolized by colonic bacteria into monosaccharides and then to volatile fatty acids, hydrogen and methane. Lactulose decreases both the production and absorption of ammonia mainly through the presence of gut bacteria. The question arises as to how lactulose decreased ammonia levels in this patient without a large bowel. One proposed mechanism is the translocation of bacteria normally found in the large bowel to the small intestine. Small Intestinal Bacterial Overgrowth (SIBO), is a condition causing an increased number of bacteria in the small intestine. Patients with IBD and structural abnormalities are at increased risk of developing SIBO. Lactulose is commonly used in the diagnosis through the administration of lactulose and subsequent measurements of hydrogen and methane gas in expired air. This condition, in our patient with history of ulcerative colitis and colectomy, is a proposed mechanism of the efficacy of lactulose in the treatment of hepatic encephalopathy.

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.

Post-Operative Outcomes in 'Monti' Construction for Neurogenic Bladders in an Adult Population

INTRODUCTION AND OBJECTIVE: Various diversion techniques exist for the management of neurogenic bladders. In pediatrics, the appendicovesicostomy is a successful approach but may not be applicable for all patients. An alternative is the Yang-Monti ("Monti") catheterizable conduit, created using a section of small bowel. Although commonly used in pediatrics, there are very few series evaluating adults. This study aims to evaluate "Monti" outcomes in an adult population. METHOD(S): Between 1999 and 2022, "Monti" procedures at a single institution were identified using CPT codes, and the list was reviewed to select for adult patients with neurogenic bladder dysfunction. Preoperative data included indications for surgery and patient demographics. Perioperative (day 0 to end of hospital stay) data included time to return of bowel function, length of stay, and perioperative complications. Long-term complications included infections, hospital admissions, and reoperations. Data are presented as means or percentages. RESULT(S): 21 adult patients (male n=8;female n=13) with neurogenic bladder dysfunction were identified. 14 patients developed neurogenic bladder secondary to trauma, while other indications for surgery included idiopathic urinary retention (n=1), tumors (n=2), congenital abnormalities (n=2), multiple sclerosis (n=1), and autoimmune neuropathy (n=1). The mean follow-up time was 3.13 years and mean age at surgery was 35.5 years. The mean time to return of bowel function was 2.7 days (n=14) and postoperative hospital stay was 4.3 days (n=16). Perioperative complications occurred in 10 patients (47.6%) in the first 30 days including UTIs (n=3), surgical site infection (n=3), ileus (n=1), small bowel obstruction (n=1), and suprapubic tube related complications (n=3). Five emergency room admissions for urologic concerns occurred within this period with a total of 28 visits overall. At six month follow-up, a total of six (28.6%) patients had longer-term complications. These included a takedown, a scheduled revision, a hospitalization for complicated UTI, and three patients who were unable to catheterize. Overall, nine patients (42.9%) required reoperation, including three revisions and one cystectomy with conversion to ileal conduit. Two patients expired during the course of this study due to COVID pneumonia and suspected sepsis. CONCLUSION(S): "Monti" procedures are useful for adult patients with neurogenic bladder dysfunction. However, these procedures are associated with significant complications. This information should be used to aid in presurgical counseling.

Recurrent intussusception with ileal perforation as a complication of Blue Rubber Bleb Nevus Syndrome in a pediatric patient

Blue rubber bleb nevus syndrome (BRBNS) is a rare congenital condition, characterized by multiple venous malformations that may involve any organ system, most commonly the skin or the gastrointestinal tract. These lesions are often responsible for chronic blood loss and secondary anemia, and in rare situations may cause severe complications such as intussusception, volvulus, and intestinal infarction. Intussusception as a complication of BRBNS, although a known complication of the disease, has rarely been reported, especially in the Philippines. In the Philippine Society for Orphan Disorders, only 2 cases of BRBNS are currently included in the organization, including the patient presented in the case report. The treatment of BRBNS that involves the gastrointestinal tract depends on the extent of intestinal involvement and severity of the disease. The treatment aims to preserve the GI tract as much as possible due to the high recurrence in the disease. In this case report, we present a 13 year-old male with BRBNS with previous history of intussusception, successfully managed conservatively;however, upon recurrence, underwent exploratory laparotomy wherein a subcentimeter perforation in the antimesenteric border of the proximal ileum was noted, together with a gangrenous intussuscipiens, and multiple mulberry-like formations on the antimesenteric border of the small bowels. Histopathological findings of the resected bowels showed multiple cavernous hemangiomas consistent with BRBNS. The postoperative course of the patient was unremarkable.Copyright © 2023 The Authors

Characterization and Evaluation of the Pathogenicity of a Natural Gene-Deleted Transmissible Gastroenteritis Virus in China

Porcine transmissible gastroenteritis virus is the major pathogen that causes fatal diarrhea in newborn piglets. In this study, a TGEV strain was isolated from the small intestine of diarrhea piglets in Sichuan Province, China, and designated SC2021. The complete genomic sequence of TGEV SC2021 was 28561 bp, revealing a new natural deletion TGEV strain. Based on phylogenetic analyses, TGEV SC2021 belonged to the Miller cluster and was closely related to CN strains. The newborn piglets orally challenged with TGEV SC2021 showed typical watery diarrhea. In addition, macro and micropathological changes in the lungs and intestines were observed. In conclusion, we isolated a new natural deletion virus strain and confirmed that the virus strain has high pathogenicity in newborn piglets. Moreover, macroscopic and microscopic lesions were observed in the lungs and intestines of all TGEV SC2021-infected piglets. In summary, we isolated a new natural deletion TGEV strain and demonstrated that the natural deletion strain showed high pathogenicity in newborn piglets. These data enrich the diversity of TGEV strains and help us to understand the genetic evolution and molecular pathogenesis of TGEV.

Cyclic [68Ga] and [18F]AlF-labeled peptides for specific detection of human angiotensin-converting enzyme 2

Objectives: In this study, we developed angiotensin-converting enzyme 2 (ACE2)-specific, peptide-derived 68Ga- and 18F-labeled radiotracers, motivated by the hypotheses that ACE2 is an important determinant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) susceptibility and that modulation of ACE2 in coronavirus disease 2019 (COVID-19) drives severe organ injury. Our current efforts are focusing on broader dissemination of ACE2-targeted PET radiotracers based on chelation of [18F]AlF enabling advanced murine and potentially human studies. Method(s): A series of NOTA-conjugated peptides derived from the known ACE2 inhibitor DX600 were synthesized, with variable linker identity. Since DX600 bears 2 cystine residues, both linear and cyclic peptides were studied. An ACE2 inhibition assay was used to identify lead compounds, which were labeled with 68Ga and 18F-AlF to generate the corresponding peptide radiotracers (68Ga-NOTA-PEP). The most potent 68Ga and 18F-AlF DX600 derivatives were subsequently studied in a humanized ACE2 (hACE2) transgenic model. Result(s): Cyclic DX-600-derived peptides had markedly lower half-maximal inhibitory concentrations than their linear counterparts. The 3 cyclic peptides with triglycine, aminocaproate, and polyethylene glycol linkers had calculated half-maximal inhibitory concentrations similar to or lower than the parent DX600 molecule. Peptides were readily labeled with 68Ga and 18F-AlF, and the biodistribution of both tracers was determined in an hACE2 transgenic murine cohort. Pharmacologic concentrations of coadministered NOTA-PEP (blocking) showed a significant reduction of 68Ga-NOTA-PEP4 signals in the heart, liver, lungs, and small intestine. Ex vivo hACE2 activity in these organs was confirmed as a correlate to in vivo results. The biodistribution of both tracers was similar, with apparent blocking observed in the lungs using the 18F-AlF peptide that needs to be verified via additional experiments. Conclusion(s): NOTA-conjugated cyclic peptides derived from the known ACE2 inhibitor DX600 retain their activity when N-conjugated for 68Ga or 18F-AlF chelation. In vivo studies in a transgenic hACE2 murine model using the lead tracer, 68Ga-NOTA-PEP4, showed specific binding in the heart, liver, lungs and intestine-organs known to be affected in SARS-CoV-2 infection. Blocking studies using the 18F-AlF labeled correlate showed modulation of PET signals in the normal lungs. These results suggest that 68Ga-NOTA-PEP4 or the 18F-AlF correlate could be used to detect organ-specific suppression of ACE2 in SARS-CoV-2-infected murine models and COVID-19 patients.Copyright © 2023 Southern Society for Clinical Investigation.

Application of a Novel Swallowable Telemetric Device for Real Time Luminal Blood Detection to Guide Timing of Enteroscopy in a Patient with Obscure-Occult Gastrointestinal Bleeding: A Case Report

Background and aim: Gastrointestinal (GI) bleeding is deemed "obscure" when upper and lower GI endoscopy reveal no bleeding site. While the term "overt" is used in cases where visible blood passage is observed or reported, cases without macroscopic bleeding stigmata are defined "occult". Although small bowel origin accounts for only about 5% of all GI bleedings, it makes up the majority of obscure GI bleedings. Diagnostic work-up and treatment of small bowel GI bleedings can be challenging, especially when overt bleeding symptoms are absent. Material(s) and Method(s): We report the case of a frail patient with multiple comorbidities and evidence of bleeding small bowel angiodysplastic lesions on videocapsule assisted enteroscopy (VCE). Device assisted enteroscopy (DAE), planned in order to treat the bleeding lesions, was delayed after the patient contracted SARSCoV- 2 infection. Eight weeks after, in the absence of clinical signs of bleeding, a device for real time luminal blood detection (HemoPillR acute, Ovesco) was applied to guide timing of enteroscopy. Result(s): The 71 year old male patient was on dual anti platelet therapy and had persistent clinical features of iron deficiency anemia (Hemoglobin 8,0g/dl). Upper and lower GI endoscopy were negative for potential bleeding sources. VCE showed three small lesions suspect for angiodysplasia within 1 to 13 minutes after pylorus passage. Upon recovery from SARS-CoV-2 infection and congestive heart failure with respiratory insufficiency, we administered HemoPillRacute orally, without previous bowel preparation. The measurement showed a peak HemoPillR-Index (HI max) at 1h 47min after capsule administration (Fig. 1) and was therefore indicative of a small bowel bleeding site, best approachable by antegrade oral route, in keeping with the prior VCE findings. On subsequent DAE, performed through spiral enteroscopy, the small bowel angiodysplastic lesions were successfully treated. [Figure presented] Conclusion(s): Our case report illustrates how a novel telemetric blood detection measurement was able to confirm luminal blood presence and successfully guide timing of therapeutic DAE in a patient with obscure-occult GI bleeding, without the need for repetition of VCE.Copyright © 2023. Editrice Gastroenterologica Italiana S.r.l.

Idiopathic anomalous congenital band causing small intestinal obstruction in a 5-month-old dog

A 5-month-old, intact male, yellow Labrador retriever was presented with a 24-hour history of anorexia and vomiting. Abdominal imaging revealed the presence of a mechanical obstruction in the jejunum and peritoneal effusion. Cytologic evaluation and culture of the effusion prior to surgery identified a suppurative exudate with bacteria consistent with septic peritonitis and suspected to be related to the intestinal lesion. An exploratory laparotomy was performed, and a segment of jejunum was circumferentially severely constricted by an off-white, fibrous band of tissue. Resection and anastomosis of the strangulated segment of jejunum and excision of the constricting band provided resolution of the clinical signs. The dog made a complete recovery. Histologic evaluation revealed the band to be composed of fibrovascular and smooth muscle tissue, consistent with an idiopathic anomalous congenital band. No other gastrointestinal lesions were observed, either grossly at surgery or histologically in the resected segment of intestine. To our knowledge, a similar structure has not been reported in the veterinary literature.Copyright © 2022 Canadian Veterinary Medical Association. All rights reserved.

Acute Pancreatitis in Early Postpartum Woman with Confirmed Covid-19: A Rare Case Report

Background: The Coronavirus disease 2019 (COVID-19) pandemic is a significant challenge for public health and clinical medicine. COVID-19 mainly impairs the respiratory tract. However, gastrointestinal manifestations of COVID-19 are increasingly being recognized. Although acute viral pancreatitis has been described in other viral infections, pancreatic involvement in SARS-CoV-2 disease is still poorly defined. We reported a case of acute maternal pancreatitis in an early postpartum period woman with confirmed COVID-19. Case Presentation: A 31-year-old woman in term pregnancy had a caesarean section due to acute respiratory distress syndrome (ARDS) caused by COVID-19 pneumonia. One day after surgery, her stomach appeared bloated, bowel sounds were weak, and her abdominal circumference increased. Ultrasound examination did not reveal any suspicion of bleeding or hematoma. Her abdominal contrast-enhanced computerized tomography (CT) scan showed small bowel obstruction and oedematous pancreas. Amylase levels increased to 382 units/litre and lipase levels to 724 units/litre. C-reactive protein and procalcitonin were also increased. The diagnosis of sepsis was made, and she received broad-spectrum antibiotics and treatment for the COVID-19 infection. Recovery was characterized by a gradual resolution of abdominal and pulmonary signs and symptoms. A decline of amylase and lipase was observed by the tenth day. On the 13th day, she was extubated and gradually recovered from respiratory symptoms, with a negative result for COVID-19 RT-PCR. Based on this case, we consider that pregnancy and COVID-19 support each other as the cause of acute pancreatitis. Conclusion(s): Early diagnosis and severity classification are essential steps for successful management because late recognition and treatment may allow a greater prevalence of associated complications.Copyright © 2022, Philippine College of Physicians. All rights reserved.

Attenuation of a Highly Pathogenic Porcine Deltacoronavirus Strain CZ2020 by a Serial Passage In Vitro

Porcine deltacoronavirus (PDCoV) is an emerging swine coronavirus that causes severe diarrhea to pigs of all ages, especially the suckling piglets under one-week-old. We previously isolated a highly pathogenic PDCoV strain, CZ2020, from a diarrheal piglet and have passaged it for over 100 passages. The adaptability of the CZ2020 increased gradually in vitro as the passage increased. Amino acid mutations were observed in pp1a, pp1ab, spike, envelop, and membrane proteins, and the spike protein accounts for 66.7% of all amino acid mutations. Then, the high passage strains, CZ2020-F80 and CZ2020-F100, were selected for evaluation of the pathogenicity in three-day-old piglets to examine whether these amino acid changes affected their virulence. At 2 days postchallenge (DPC), 2/5 piglets started to show typical diarrhea, and at 4 DPC, severe diarrhea was observed in the CZ2020-challenged piglets. Viral RNA could be detected at 1 DPC in rectal swabs and reached its highest at 4 DPC in the CZ2020-challenged group. CZ2020-F80- and CZ2020-F100-challenged groups have one piglet exhibiting mild diarrhea at 4 and 6 DPC, respectively. Compared with the CZ2020-challenged group, the piglets in CZ2020-F80- and F100-challenged groups had lower viral loads in rectal swabs, intestines, and other organs. No obvious histopathological lesions were observed in the intestines of CZ2020-F80- and F100-challenged piglets. Virulent PDCoV infection could also induce strong interferons and proinflammatory cytokines in vitro and in vivo. These data indicate that the strains, CZ2020-F80 and CZ2020-F100, were significantly attenuated via serial passaging in vitro and have the potential for developing attenuated vaccine candidates.

A CASE OF SEVERE COVID-19 WITH PERSISTENT MASSIVE DIARRHEA.

A 63-year-old man was admitted to our hospital with sore throat and fever. He was diagnosed with Coronavirus Disease 2019(COVID-19), and on the 3rd day after diagnosis, he started on ventilatory management. On the 25th day, the patient presented with over 3 L of watery diarrhea, which continued daily. When the diarrhea did not improve with various treatments, on the 98th day, a double-balloon endoscopy of the small intestine was performed, and diffuse loss of villi structure in the jejunum was noted. Due to massive pleural effusion, the patient succumbed to circulatory and respiratory failure 111 days after admission to the hospital. The pathological autopsy revealed that the mucosal epithelium had been exfoliated from the entire small intestine. As this case shows, some COVID-19 cases are associated with severe diarrhea;further investigation is needed to elucidate the pathogenesis of COVID-19-associated diarrhea.Copyright © 2023 Authors. All rights reserved.

Molecular identification and characterization of SARS-Co V-2 from the clinical stool and sewage samples to study waste water-based epidemiology and monitoring circulating virus

The Coronaviridae family's severe acute respiratory syndrome corona virus 2 (SARS-Co V-2) outbreak has infected a large number of the population during the COVID- 19 pandemic. The most prominent mode of virus transmission is considered through respiratory droplets of the infected person. Virus-mediated respiratory infection depends upon the binding between spike protein and the Angiotensinconverting enzyme 2 (ACE2) receptor expressed in lung alveolar type 2 cells. But some studies reported that gastrointestinal infection is also one of the prominent symptoms of COVID-19 because of the high expression of the ACE2 receptor in absorptive enterocytes of the small intestine. In a country like India, with high population density and due to unhygienic sanitation, it is crucial to understand the potential fecal-oral transmission route of SARS-CoV-2 during infection because of presence of ACE2 in small intestine. Therefore in our study, we aim to trace the potential fecal-oral transmission route of SARS-Co V-2 by examining human stool (collected from hospital settings) and nearby sewage water systems, followed by molecular characterization and viral load kinetics evaluation of SARSCOV- 2. qRT-PCR and NGS sequencing methods were used. The presence of SARS-COV-2 was reported in around 70% of samples (both clinical and environmental), this will help us to establish the epidemiological link between clinical and environmental samples after genomic analysis to alter the circulation of silent SARS Co V2 in the community.

Using urgent small bowel ultrasound (SBUS) as a tool for decision-making in patients with inflammatory bowel disease (IBD): Retrospective analysis of United Kingdom (UK) patients' outcome

Background: In the UK, magnetic resonance enterography (MRE) and colonoscopy are the gold standard assessment for mucosal disease activity in IBD. Both techniques require bowel preparation, may be poorly tolerated and are often subject to delay due to capacity issues. In several European centres, ultrasound is used as an alternative tool for disease activity monitoring and clinical decision-making. Recent studies confirm excellent sensitivity, specificity, correlation with MRE / colonoscopy and robust inter-observer agreement. In the UK, a lack of US training in IBD physicians has hindered development of accessible SBUS. In view of issues with MRI capacity during the covid pandemic, a dedicated small bowel ultrasound list with a gastroenterology fellow and a specialist radiology consultant for urgent IBD patients was initiated. Method(s): Records of IBD patients undergoing SBUS between June 2022 and November 2022 were reviewed. SBUS assessed disease activity (vascularity, bowel wall thickness, mesenteric fat and lymphnodes), length of disease, presence of obstruction or fistulating disease. Patients were then retrospectively asked to rate their SBUS experience compared to previous MREs. Result(s): 53 SBUS's (46 (86.7%) CD;2 (3.7%) UC) were performed on a dedicated SBUS list by a gastroenterology fellow and specialist radiology consultant during the study. In 29 patients (54.7%), the area of interest was the terminal ileum. SBUS detected disease complications in 7 (2 (3.7%) patients with obstructive disease, and 5 (9.4%)) patients with penetrating disease. The average waiting time from the point of referral to SBUS was 4.7 weeks, compared to an average waiting time for MRE of 20 weeks. Treatment response was assessed in 18 patients (33.9%). We were able to make treatment decisions with 32 patients (60.3%) based on their SBUS results without further assessment. In 10 patients (18.8%), SBUS was used to confirm a diagnosis in addition to colonoscopy. 18/22 ( 81%) patients reported a preference for SBUS compared to MRE (preference score of 4.5 on scale of 1-5). Conclusion(s): We developed an urgent SBUS service to aid timely clinical decision-making for IBD patients. In our practice, SBUS is an accurate tool to assess disease activity, significantly reduces patients waiting times and is the patient's preferred investigation. There is a clear unmet need to train IBD doctors and radiologists in SBUS.