Amyloid Light-Chain (AL) Amyloidosis of the Trachea Associated With an Indolent B-cell Neoplasm.

We report the case of a 66-year-old woman who was diagnosed with localized tracheal amyloid light-chain (AL) amyloidosis caused by an underlying B-cell neoplasm. The diagnosis was confirmed through subsequent bronchoscopy and biopsies; however, she experienced a challenging episode of hypoxic respiratory failure that required intervention. Repeat bronchoscopies showed persistent subglottic stenosis and tracheobronchomalacia, which led to tracheal debulking surgery and additional interventions. The patient's treatment began with rituximab, zanubrutinib, and dexamethasone with outpatient follow-up. The rarity of tracheobronchial amyloidosis and its connection to B-cell malignancies are highlighted, emphasizing the challenges in diagnosis and the importance of tailored treatment strategies. The patient's clinical course, characterized by atypical respiratory symptoms, delayed diagnosis, and an evolving treatment approach, underscores the complexities of managing such a rare and intricate case.

Recent advances in endoscopic management of gastric neoplasms.

The development and clinical application of new diagnostic endoscopic technologies such as endoscopic ultrasonography with biopsy, magnification endoscopy, and narrow-band imaging, more recently supplemented by artificial intelligence, have enabled wider recognition and detection of various gastric neoplasms including early gastric cancer (EGC) and subepithelial tumors, such as gastrointestinal stromal tumors and neuroendocrine tumors. Over the last decade, the evolution of novel advanced therapeutic endoscopic techniques, such as endoscopic mucosal resection, endoscopic submucosal dissection, endoscopic full-thickness resection, and submucosal tunneling endoscopic resection, along with the advent of a broad array of endoscopic accessories, has provided a promising and yet less invasive strategy for treating gastric neoplasms with the advantage of a reduced need for gastric surgery. Thus, the management algorithms of various gastric tumors in a defined subset of the patient population at low risk of lymph node metastasis and amenable to endoscopic resection, may require revision considering upcoming data given the high success rate of en bloc resection by experienced endoscopists. Moreover, endoscopic surveillance protocols for precancerous gastric lesions will continue to be refined by systematic reviews and meta-analyses of further research. However, the lack of familiarity with subtle endoscopic changes associated with EGC, as well as longer procedural time, evolving resection techniques and tools, a steep learning curve of such high-risk procedures, and lack of coding are issues that do not appeal to many gastroenterologists in the field. This review summarizes recent advances in the endoscopic management of gastric neoplasms, with special emphasis on diagnostic and therapeutic methods and their future prospects.

Review of existing evidence demonstrates that methotrexate does not cause liver fibrosis.

It has long been believed that methotrexate in therapeutic doses causes progressive liver injury resulting in advanced fibrosis and cirrhosis. Historically, this was a common indication for serial liver biopsy. However, new evidence suggests that methotrexate may not be a direct cause of liver injury; rather the injury and fibrosis attributed to methotrexate may be mediated by other mechanisms, specifically non-alcoholic fatty liver disease. The recent widespread use of non-invasive assessment of liver fibrosis has provided new evidence supporting this hypothesis. Thus, we conducted a meta-analysis and systematic review to determine whether methotrexate is indeed a direct cause of liver injury. For the meta-analysis portion, a comprehensive literature search was performed to identify manuscripts relevant to the topic. Of the 138 studies examined, 20 met our inclusion criteria. However, only 3 studies had sufficient homogeneity to allow aggregation. Thus, the remainder of the study was dedicated to a critical review of all studies relevant to the topic with particular attention to populations examined, risk factors, and assessment of injury and/or fibrosis. Meta-analysis did not show a statistically significant association between methotrexate dose and liver fibrosis. Individual studies reported fibrosis related to confounding factors such as diabetes, obesity, pre-existing chronic liver disease but not methotrexate exposure. In conclusion, existing evidence demonstrates that advanced liver fibrosis and cirrhosis previously attributed to methotrexate are in fact caused by metabolic liver disease or other chronic liver diseases, but not by methotrexate itself. This observation should direct the care of patients treated with long-term methotrexate.

Comparison Between Intravenous and Intramuscular Octreotide in the Management of Heyde's Syndrome.

Heyde's syndrome is defined as a triad of aortic stenosis, anemia due to angiodysplasia-related bleeding, and von Willebrand syndrome type 2A. It is a rare disease and a diagnostic challenge. Treatment modalities include symptomatic management, blood transfusions, aortic valve replacement, and medications such as octreotide. Here, we report the case of a patient who was resistant to symptomatic management, aortic valve replacement, as well as intravenous octreotide.

A Case of Duodenal "Spot" Diagnosis.

Pseudomelanosis duodeni is a rare finding usually described as a black/brown speckled or tattooed appearance of the intestinal mucosa. Although an incidental finding, it has been associated with different medications and chronic medical conditions such as diabetes mellitus and chronic renal failure. We describe an elderly male who presented with epigastric pain and melena. Endoscopy showed pseudomelanosis duodeni related to intravenous (IV) iron transfusion. To our knowledge, this is the first report of pseudomelanosis duodeni related to IV iron use. In spite of its benign nature, the diagnosis of pseudomelanosis duodeni is essential to rule out other serious medical conditions that mimic its physical findings.

Big Brother Is Watching: Artificial Intelligence in Endoscopy - Hype or Reality?

Artificial intelligence (AI) has become a part of many image-based specialties, such as radiology and pathology, as well as medical specialties in which "oscopy" is the key to current practice. In gastroenterology, for example, AI is being explored as an aid to endoscopists to visually distinguish precancerous lesions in upper and lower endoscopy. Although there have been a variety of approaches to the employment of AI for this purpose, deep-learning algorithms, which combine the extraction and classification of image features using deep neural networks,1 have the capability of self-learning.

Association study of interleukin-1 receptor associated kinase 1 rs3027898 A/C gene polymorphism and preeclampsia in Pakistani population.

OBJECTIVES: To find the association between interleukin-1 receptor-associated kinase 1 rs3027898 gene polymorphism and preeclampsia. METHODS: The case-control study was conducted from October, 2018 to September, 2019 at the Railway General Hospital and the Department of Biochemistry, Islamic International Medical College, Rawalpindi, Pakistan, and comprised patients diagnosed with preeclampsia and healthy controls. The interleukin receptor-associated kinase-1 polymorphism was determined using multiplex tetra primer amplification refractory mutation system polymerase chain reaction. Outcomes were determined in terms of association of interleukin receptor-associated kinase-1 with preeclampsia. Data was analysed using SPSS 22. RESULTS: Of the 160 subjects, 80(50% were cases with a mean age of 30±5.3 years and 80(50%) were controls with a mean age of 27±3.7 years. AC genotype was seen in 45(56.25%) cases and 30(37.5%) controls, AA genotype in 25(31.25%) cases and 30(37.5%) controls, while CC genotype was seen in 10(12.5%) cases and 20(25%) controls (p>0.05). CONCLUSIONS: There was no significant association of interleukin receptor-associated kinase-1 genotypes with preeclampsia.

Propofol Infusion and Acute Pancreatitis: A Review.

BACKGROUND: Propofol is a short-acting anesthetic used to induce sedation in various ambulatory and inpatient surgical procedures. It is a US Food and Drug Administration approved lipid-based intravenous hypnotic agent, which has been used clinically for the induction and maintenance of anesthesia for over 3 decades. In addition to general anesthesia, it is used to sedate patients undergoing mechanical ventilation or short procedures such as endoscopy, transesophageal echocardiogram, and abscess drainage. An infrequent but serious complication of propofol is acute pancreatitis (AP), with potentially significant morbidity and possible mortality. In this review, we will discuss the proposed mechanisms of AP secondary to propofol, a number of reported cases, studies conducted, and treatment strategies. AREAS OF UNCERTAINTY: There are several case reports in the literature that have shown an association between propofol and pancreatitis. The exact mechanism behind propofol-induced pancreatitis is not fully understood, but proposed mechanisms include hypertriglyceridemia (HTG), hypersensitivity, or direct pancreatic toxicity of the drug. Although the association of propofol and pancreatitis has not been proven conclusively, clinicians should be aware of this possible rare complication to prevent the devastating consequences of AP. DATA SOURCES: We gathered articles on previously documented case reports and up-to-date studies on propofol-induced pancreatitis by searching databases such as PubMed and Google Scholar. RESULTS: Based on previous studies and case reports, we suggest that propofol should be added to a list of drugs having a direct association with AP. CONCLUSIONS: Although, the mechanism of propofol-induced pancreatitis is not fully understood, and the causal relationship of propofol-induced hypertriglyceridemia or idiosyncratic drug reaction has remained unproven. Clinicians should be aware of the association between propofol and pancreatitis, and any patient presenting with abdominal pain after propofol infusion should be evaluated for AP and treated promptly to avoid complications.

Swan-Ganz catheter causing anaphylactic shock: A rare case report.

Latex-induced anaphylactic reactions are often underestimated in patients having procedures in a catheterization lab, intensive care units, or in operating rooms. Most physicians are not aware that almost all balloons in the Swan-Ganz catheter (SGC) are made up of latex. Direct exposure of these latex balloons in the blood can cause severe anaphylactic reactions, even in patients with no previous history of allergies. We present a case of a 53-year-old male, who underwent a SGC placement for cardiovascular evaluation. Immediately after the SGC insertion, he developed circulatory shock. On further investigation, we discovered that SGC balloon contained latex as one of the components. Physicians should be aware of latex-based products such as SGC balloon, which can cause anaphylactic shock even in case of no prior allergies to latex.

Sputum Smear and Culture-negative Tuberculosis with Associated Pleural Effusion: A Diagnostic Challenge.

Tuberculosis (TB) is an important cause of morbidity and mortality in the United States. Due to the unpredictable or nonspecific nature of its clinical presentations, TB can be a diagnostic challenge for physicians. In 2013, 23% of reported TB cases were culture-negative in the United States; in New York City, this was approximately 27%. The increasing number of sputum smear- and culture-negative TB patients is a serious concern because misdiagnosis and delayed treatment can lead to increased morbidity and mortality and increased infectious transmission. We report a case of a 26-year-old-female recent immigrant, who was initially managed for community-acquired pneumonia but was later found to have TB with complicated pleural effusion, despite having multiple smear- and culture-negative sputum specimens, Xpert Mycobacterium tuberculosis (MTB)/resistance to rifampin (RIF) assay (real-time polymerase chain reaction (PCR)) and pleural fluid analysis. She improved clinically on anti-tuberculosis therapy and, later, the diagnosis was confirmed by pleural biopsy.

Type II Renal Tubular Acidosis Secondary to Topiramate: A Review.

Topiramate (TMP) is a broad-spectrum anticonvulsant drug used to treat a wide variety of seizure disorders, for migraine prophylaxis, and for many other indications. An important side effect of TMP is metabolic acidosis, which is mediated by renal tubular defects. TMP inhibits carbonic anhydrase, an enzyme that is necessary for acid handling in the proximal renal tubule. Patients can present with asymptomatic serum electrolyte derangements, acute change in mental status, hyperventilation, cardiac arrhythmias, or other sequelae of metabolic acidosis and associated respiratory compensation. If taken chronically, TMP can cause renal stone formation, bone mineralization defects, and several other effects secondary to changes in serum and urine pH and electrolytes. There is no well-studied way to prevent metabolic acidosis in patients taking TMP, but physicians should be vigilant when prescribing this drug to patients with the history of renal diseases and other comorbidities, and aware of this potential etiology of metabolic acidosis. We present a literature review of the underlying mechanisms involved in the development of renal tubular acidosis secondary to TMP and its clinical consequences.

Postprandial Hypoglycemia: Complication of Peptic Ulcer Surgery.

OBJECTIVE: Billroth II procedures (gastrojejunostomy with vagotomy) are seldom performed now but were popular before the advent of histamine 2 receptor blockers and proton pump inhibitors. Such procedures can be a cause of late postprandial hypoglycemia. METHODS: We performed a formal evaluation and discussion of postprandial hypoglycemia. RESULTS: We present a case of an 85-year-old man who presented to the endocrinology clinic with symptoms of "fainting spells after large meals." The patient previously had extensive evaluations by a neurologist and a cardiologist. Because of the history of Billroth II surgery and the description of his fainting spells, a 5-hour glucose tolerance test was performed in the clinic using the foods that uniformly resulted in symptoms. This confirmed that the late dumping syndrome with associated hypoglycemia was the cause of his spells. CONCLUSIONS: Late dumping syndrome manifesting with hypoglycemia should be considered in the workup of patients with a history of gastric surgery and unusual postprandial symptoms. This case highlights the importance of an appropriate workup that can lead to avoidance of unnecessary testing in such patients.

Disseminated Coccidioidomycosis Presenting as Carcinomatosis Peritonei and Intestinal Coccidioidomycosis in a Patient with HIV.

Coccidioidomycosis (CM) is a fungal infection endemic in southwestern regions of the United States, northwestern regions of Mexico, and some areas of Brazil and Argentina. Clinical presentation varies depending on the extent of the infection and the immune status of the host. The most common presentation ranges from flu-like symptoms to self-limiting pneumonia. Extrapulmonary presentations are uncommon and may involve the meninges, skin, and bone. Gastrointestinal and peritoneal involvement is extremely rare. Here we report a case of disseminated CM presenting as carcinomatosis peritonei as an AIDS-defining illness in a young male.

Levonorgestrel-Releasing Intrauterine Device-Related Acute Liver Injury.

Oral contraceptives have long been associated with liver injury. However, very little attention is paid to the metabolic side effects of hormone-releasing intrauterine devices (IUDs). These devices are generally considered safe and commonly used. We report for the first time acute liver injury associated with a levonorgestrel-releasing IUD. Our patient did not have any comorbidities that could have caused or exacerbated liver injury. A detailed workup and liver biopsy remained negative for any other potential cause of liver injury. The patient's symptoms resolved with removal of the device. She remained symptom free on subsequent outpatient follow-ups.