Hemorrhagic Shock After Transrectal Ultrasound-Guided Prostate Biopsy Successfully Treated With Endoscopic Therapy.

Prostate cancer is the second cause of cancer-related deaths among men in the United States. Transrectal ultrasound-guided prostate biopsy is the gold standard for diagnosis of prostate cancer. This is a relatively safe procedure, yet bears the small risk of hemorrhage. In rare instances, the bleeding may require emergent endoscopic or radiologic therapy. However, scarce literature exists depicting the appearance of the bleeding lesions and the successful endoscopic therapies used to treat them. In this report, we present a case of a 64-year-old man who developed massive bleeding after transrectal ultrasound-guided prostate biopsy that was successfully treated with epinephrine injection and endoscopic hemoclipping.

Botrytis cinerea response to pulsed light: Cultivability, physiological state, ultrastructure and growth ability on strawberry fruit.

Botrytis cinerea causes postharvest spoilage in important crops such as strawberry and other berries. Pulsed light (PL) treatment could be an environmentally friendly postharvest alternative to synthetic fungicides in berries. Cultivability, physiological state, ultrastructure of Botrytis cinerea suspended in peptone water and irradiated with PL (fluence = 1.2 to 47.8 J/cm2) were investigated by using conventional plate count technique, flow cytometry analysis (FCM) and transmission electron microscopy. In addition, PL effect on B. cinerea development in artificially contaminated strawberries throughout storage at (5 ±â€¯1) °C was evaluated. PL reduced fungus' ability to form colonies on agarized culture media. Survival curve fitted with the Weibullian model evidenced a wide distribution of conidia sensitivity to PL. FCM showed that most of irradiated conidia entered in a viable non-culturable state, although a subpopulation without esterase activity and compromised membranes and a subpopulation with active esterase and intact membranes were also detected. PL attacked multiple targets in B. cinerea. Ultrastructural changes varied with the dose and within the conidia population, supporting FCM results. Damage included plasmalemma detachment from cell wall, cytoplasm collapse, and vacuolization of cytoplasm, disruption of cell wall and plasmalemma with massive loss of cytoplasm and/or disruption of organelles. In strawberries artificially contaminated with B. cinerea, a 2-day delay on the onset of the infection and a lower incidence in PL-treated strawberries (11.9 and 23.9 J/cm2) compared to control (16-20%) up to 10 days of cold storage was observed. Results indicated that PL significantly reduces B. cinerea growth in peptone water and in inoculated strawberries. However, other preservation factor(s) in combination would be needed to increase PL action for a better control of this fungus.

Sorafenib-induced Facial Acneiform Eruption.

Sorafenib is a multikinase inhibitor that is used to treat hepatocellular carcinoma by inhibiting tumor cell growth and angiogenesis. Cutaneous adverse events of sorafenib are commonly reported, with alopecia and hand-foot skin reactions most frequently encountered. Acneiform eruptions represent rare adverse events that have only been reported at high doses of sorafenib. We present a patient who started low dose sorafenib for hepatocellular carcinoma and subsequently developed a fulminant facial acneiform eruption in the absence of other cutaneous adverse events. Treatment included topical clindamycin and tretinoin with some improvement. Facial acneiform eruption represents a rare consequence of sorafenib that has not previously been described at low doses. Additionally, acneiform papules in the absence of other cutaneous adverse events is unusual. The cutaneous mechanism is not well understood but may be related to indirect epidermal growth factor receptor inhibition or direct cytotoxic effects on eccrine glands. Topical treatment produces only minimal improvement in patients who continue sorafenib therapy. Discontinuation of the drug is usually unwarranted except in special circumstances.

Diagnosis of Primary Colorectal Carcinoma with Primary Breast Cancer: Associations or Connections?

Introduction Although once very uncommon, multiple primary malignant neoplasms (MPMN) are becoming an increasingly popular subject in medical literature. With 182,000 new diagnoses per annum, breast cancer is the most frequently diagnosed cancer amongst women in the United States. Colorectal cancer remains the second most commonly diagnosed cancer in females, and the third in males worldwide. Methods In order to gather literature on synchronous and metachronous occurring breast and colon cancer, we searched PubMed using keywords such as 'colorectal cancer', 'breast cancer', and 'MPMN'. We searched through case reports, case series, clinical trials, letters to the editor, and retrospective series. We included any manuscript in English published between January 1990 and January 2019. The articles featured patients who had primary colorectal cancer with primary breast cancer. Articles featuring patients with more than two malignancies or malignancies other than colorectal and breast cancer were excluded. Furthermore, any metastatic cancers were excluded as well. This narrowed our search down from over 100 manuscripts to just four.  Results Fortunately, the prognosis was found to be no different for these patients with MPMN assuming diagnosis and treatment are performed in a timely fashion. Additionally, it appears that although a patient with one primary cancer is at a greater risk for the development of a second cancer, it is still an odd phenomenon and thus an unlikely occurrence. Conclusion Detection of one cancer increases the odds of detecting another cancer. Hence, it is important to consider the possibility of a synchronous tumor in a patient with a newly diagnosed colon tumor, as well as to not only consider disease recurrence when following up post-resection.

Hypomyopathic Dermatomyositis Presenting with Idiopathic CD4 T-lymphocytopenia and Delayed Anti-MDA5 Positivity.

A 47-year-old Haitian male with no known past medical history was admitted to the hospital for gradually progressive dyspnea, nonproductive cough, and weight loss. He also endorsed a one-year history of joint pains. He was febrile and tachycardic and in mild respiratory distress. Other pertinent physical examination findings included diffuse inspiratory crackles, digital ulcers, and symmetric swelling of the wrists, elbows, shoulders, and knees. He was found to have a right basilar consolidation on chest computed tomography (CT) and was placed on antibiotics for presumptive pneumonia. His CD4 count was 158 cells per microliter despite testing negative for human immunodeficiency virus (HIV). A thorough infectious workup was unrevealing, and he did not improve with antibiotics. He had a weakly positive anti-nuclear antibody (ANA) with an otherwise negative rheumatologic workup. Creatinine kinase and aspartate aminotransferase were mildly elevated in the absence of overt muscle weakness. A myositis panel, including melanoma differentiation-associated protein five (anti-MDA5) antibody, was negative at the time. He was discharged on a short course of prednisone without a definitive diagnosis. He returned several months later with worsening respiratory symptoms. At this time, a lung biopsy revealed interstitial lung disease. Repeat myositis panel demonstrated anti-MDA5 positivity. The patient was also found to have new-onset non-ischemic heart failure with reduced ejection fraction. A diagnosis of hypomyopathic dermatomyositis was made based on clinical, laboratory, and imaging findings. The patient was restarted on prednisone, and mycophenolate mofetil was subsequently initiated for maintenance therapy.

A Curious Case of Autoimmune Pancreatitis with IgG4-related Sclerosing Cholangitis.

Immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) is a novel entity that belongs to the immune-mediated fibroinflammatory class of IgG4-related diseases (IgG4-RD). IgG4-SC is noted to be one of the most frequent manifestations of extra-pancreatic disease among IgG4-RD, which is significantly different from primary SC (PSC) and cholangiocarcinoma (CC) as is evident in the varied approaches to treatment. IgG4-RD includes IgG4-SC and autoimmune pancreatitis (AIP). Herein, we presented a case of IgG4-SC in a patient with obstructive jaundice secondary to AIP. We have also discussed the current recommendations for diagnostic and treatment modalities, with an emphasis on the issues that arise in obtaining a definitive classification of disease.

Type 1 Gastric Neuroendocrine Tumor Found on Endoscopic Polypectomy.

Gastric neuroendocrine tumors (GNET) are rare gastric neoplasms accounting for <1% of all gastric neoplasms. The World Health Organization (WHO) categorized these neoplasms as types 1-3 to help predict malignant potential and long-term survival and guide management. Improved outcomes have been shown with endoscopic resections, but further studies are needed to confirm the best approach. We present a case of a 56-year-old woman who demonstrated the classic features of type one GNET with mucosal and submucosal involvement in the setting of primary atrophic gastritis, secondary hypergastrinemia, and underlying pernicious anemia. In general, standardizing treatment has been difficult due to a variable presentation.

Disseminated Central Nervous System Histoplasmosis: A Case Report.

Central nervous system (CNS) histoplasmosis is a rare manifestation of disease, often misdiagnosed due to the wide spectrum of neurological presentation. We present a rare case of CNS histoplasmosis in a 62-year-old male with untreated myeloproliferative disease who presented with altered mental status. This case emphasizes the clinical presentation and diagnostic difficulty in a patient with CNS histoplasmosis. We also highlight the importance of implementing a multidisciplinary approach in the medical management of disseminated histoplasmosis with CNS involvement.

A Rare Case of Low-grade Appendiceal Mucinous Neoplasm: A Case Report.

Low-grade appendiceal mucinous neoplasm (LAMN) is a rare malignancy with symptoms varying depending on the clinical manifestations. The most worrisome complication of this particular neoplasm is seeding of mucin into the adjacent peritoneum leading to pseudomyxoma peritonei (PMP). There is a lack of standardized treatment approach; however, an appendectomy-only approach is currently being used for the resection of non-metastatic disease. We present an unusual case of a 67-year-old male found to have LAMN status post elective appendectomy, six months after being treated for an appendiceal abscess.

A Rare Case of Mixed Adenoneuroendocrine Carcinoma of the Ileocecal Valve.

Mixed adenoneuroendocrine carcinoma (MANEC) is an uncommon neoplasm with uncertain pathophysiology. In order to be classified as MANEC, the tumor must contain at least 30% neuroendocrine cells and 30% adenocarcinoma. The standardization of MANEC treatment has historically been difficult due to the lack of diagnostic histological classification. In 2010, the World Health Organization (WHO) finally recognized this uncommon condition as a specific colon cancer entity in the hopes of better specifying treatment options in the future. We present a case of high-grade MANEC of the cecum with metastasis in 3/10 lymph nodes to further characterize the diagnostic modalities and treatment options of the disease. MANECs only account for 3%-9.6% of all colorectal cancers and only eight cases have been reported in the cecum to date, making the following case report exceptionally rare.

Celiac Artery Dissection in a Young Smoker.

Isolated dissection of the celiac artery (IDCA) is a rare phenomenon with unclear pathogenesis. Although several risk factors have been attributed, it is essential for clinicians to maintain this diagnosis in the list of differentials to ensure prompt implementation of diagnostic and treatment modalities. We present the case of a 37-year-old smoking male who presented with upper abdominal pain radiating to the left upper quadrant with associated nausea/vomiting, diaphoresis, and diarrhea.

Uremic Pancolitis in an Adult Patient with Newly Diagnosed, Rapidly Progressive Crescentic Immunoglobulin A Nephropathy.

Uremic gastroenteropathy is a well-accepted but less often described sequelae of an underlying renal disease. With the advent of modern dialysis treatments, rarer manifestations, such as pancolitis, may go overlooked in the evaluation, pursuing more common diagnoses. The underlying pathophysiology of uremic gastroenteropathy is not completely understood; however, several underlying mechanisms have been identified to play a role. Here, we present an exceptionally rare case of uremic pancolitis in a Hispanic male who presented with clinical, imaging, and pathological findings consistent with newly diagnosed, rapidly progressive crescentic IgA nephropathy (IgAN).

A Rare Case of Medullary Carcinoma of the Ileum.

Medullary carcinoma of the small intestine is an exceedingly rare tumor. These tumors account for less than 0.04% of all colorectal cancers and only one case to date has been reported in the ileum. Although the clinical manifestations can be consistent with signs of intestinal obstruction, often times they are discovered incidentally in an asymptomatic patient. Major contributing risk factors to the development include long standing inflammation such as Crohn's disease, and other chronic inflammatory illnesses. Tumor markers and imaging can aid in the diagnosis, however biopsy is needed for definitive diagnosis. Despite the fact that the development of these tumors in the ileum is rare, further enhancement of awareness can aid in the appropriate early detection and appropriate treatment modalities.

Persistent organic pollutants (POPs) in populations of the clam Chione californiensis in coastal lagoons of the Gulf of California.

This study examines the potential public health risk due to the massive use of organochlorine pesticides (OCs) in agriculture in the Gulf of California. Specimens of the clam Chione californiensis were collected from three coastal lagoons (Yavaros, Altata and Reforma). Sites were classified as polluted/nonpolluted based on the presence/absence of OCs as an indicator of the persistence of these pollutants; in polluted sites, the time elapsed since pesticide application (past or recent) was estimated. Screening values (SV) for protecting human health as per the U.S. Environmental Protection Agency (EPA) were used for risk assessment. OCs detected were ranked according to frequency of occurrence as follows: γ-chlordane (75%) > endrin (54%) > aldrin (48%) > heptachlor, and dichlorodiphenyl-trichloroethane (DDE) (37%) > ß-heptachlor epoxide (30%) > lindane (α-BHC, δ-BHC) and endosulphan I (≤ 6%). Specifically, OCs detected at the highest concentration were heptachlor in Yavaros (0.0168 µgg(-1)) and Altata (0.0046 µgg(-1)), and aldrin in Reforma (0.0019 µgg(-1)). ß-Heptachlor epoxide in Altata and Reforma was the only OC with a concentration exceeding the EPA Screening Value. From our results and based on the monthly consumption limit set forth by EPA, the maximum safe consumption of clams to avoid a carcinogenic risk derived from ß-heptachlor epoxide in the fishing villages of Yavaros and Altata is 4 servings per month (1 serving = 0.227 kg) by a 70-kg person. These findings suggest that concentrations of OCs and their isomers in C. californiensis populations reflect environmental persistence as well as recent inputs of OCs into coastal lagoons in the Gulf of California.

Mycotoxigenic potential of fungi isolated from freshly harvested Argentinean blueberries.

Alternaria alternata, A. tenuissima, Fusarium graminearum, F. semitectum, F. verticillioides, Aspergillus flavus, and Aspergillus section Nigri strains obtained from blueberries during the 2009 and 2010 harvest season from Entre Ríos, Argentina were analyzed to determine their mycotoxigenic potential. Taxonomy status at the specific level was determined both on morphological and molecular grounds. Alternariol (AOH), alternariol monomethyl ether (AME), aflatoxins (AFs), zearalenone (ZEA), fumonisins (FBs), and ochratoxin A (OTA) were analyzed by HPLC and the trichotecenes deoxynivalenol (DON), nivalenol (NIV), HT-2 toxin (HT-2), T-2 toxin (T-2), fusarenone X (FUS-X), 3-acetyl-deoxynivalenol (3-AcDON), and 15-acetyl-deoxynivalenol (15-AcDON) by GC. Twenty-five out of forty two strains were able to produce some of the mycotoxins analyzed. Fifteen strains of Aspergillus section Nigri were capable of producing Fumonisin B1 (FB1); two of them also produced Fumonisin B2 (FB2) and one Fumonisin B3 (FB3). One of the F. graminearum isolated produced ZEA, HT-2, and T-2 and the other one was capable of producing ZEA and DON. Two A. alternata isolates produced AOH and AME. Four A. tenuissima were capable of producing AOH and three of them produced AME as well. One Aspergillu flavus strain produced aflatoxin B1 (AFB1), aflatoxin B2 (AFB2), and aflatoxin G1 (AFG1). To our knowledge, this is the first report showing mycotoxigenic capacity of fungal species isolated from blueberries that include other fungi than Alternaria spp.

Mycoflora and mycotoxin contamination of Roundup Ready soybean harvested in the Pampean Region, Argentina.

A total of 89 freshly harvested soybean seed samples (Roundup Ready [transgenic] soybean cultivars) from the 2010/2011 crop season were collected from five locations in the Northern Pampean Region II, Argentina. These samples were analyzed for internal mycoflora, toxin production of isolated fungi, and for a range of mycotoxins. Mycotoxin analysis of aflatoxins (AFs), zearalenone (ZEA), fumonisins (FBs) and ochratoxin A (OTA) was done by HPLC-FLD (high performance liquid chromatography with postcolumn fluorescence derivatization), alternariol and alternariol monomethyl ether with HPLC-UV (HPLC with UV detection), trichothecenes (deoxynivalenol, nivalenol, T-2 toxin, HT-2 toxin, fusarenon X, 3-acetyldeoxynivalenol and 15-acetyldeoxynivalenol were analyzed by GC-ECD (gas chromatography with electron capture detector). Fungal colonization was more frequently found for samples from América, Saladillo and Trenque Lauquen than for samples from General Villegas and Trenel; a total of 1,401 fungal isolates were obtained from the soybean seeds. The most commonly identified fungal genera were Alternaria, Sclerotinia, Chaetomium, Cladosporium, Aspergillus, Penicillium, Phomopsis and Fusarium. Alternaria alternata, A.tenuissima, Aspergillus flavus, Penicillium citrinum, Fusarium verticillioides and F.semitectum were the predominant toxigenic fungal species. Mycotoxin production was confirmed for several isolates of toxigenic species, including Aspergillus flavus, A. parasiticus, Alternaria alternata, A.tenuissima, Fusarium graminearum, F semitectum and F. verticillioides. In particular, the percentage of mycotoxigenic Alternaria alternata (100%), A.tenuissima (95%) and aflatoxigenic strains of A. flavus (57%) were remarkably high. Although none of the mycotoxins, AFs, ZEA, FBs, trichothecenes and OTA, were directly detected in samples of soybean seeds, the frequent presence of toxigenic fungal species indicates the risk of multiple mycotoxin contamination.

Fungal and fumonisins contamination in Argentine maize (Zea mays L.) silo bags.

Fumonisins in maize (Zea mays L.) grain silo bags in the conditions of three Argentine provinces were analyzed to determine how this kind of storage affects contamination and if differential storage durations or times of the year of silo bag closing and opening are factors that could modify it. Moisture content, water activity (a(w)), molds and yeasts present, and fumonisins were analyzed in 163 maize silo bags, at the moment of closing and later at opening. Storage durations ranged from 120 to 226 days. The analysis was centered on fumonisins since most samples were only contaminated with these toxins. Fumonisins, moisture content, and a(w) increased significantly, whereas mold propagules/g and yeasts CFU/g did not present significant differences between silo opening and closing. The date on which silo bags were closed and later opened, however, did affect the level of fumonisin contamination.