Diffuse-Type Pancreatic Ductal Adenocarcinoma Mimicking Autoimmune Pancreatitis.

Pancreatic ductal adenocarcinoma (PDAC) classically presents as a solitary mass on cross-sectional imaging. Diffuse-type PDAC is an unusual variant that accounts for 1%-5% of PDACs. Owing to its rarity, there are no established radiographic or endosonographic definitions. We report a unique case of diffuse-type PDAC presenting with imaging findings of 2 distinct masses in the pancreatic head and tail and with endoscopic ultrasound findings of diffuse gland enlargement mimicking autoimmune pancreatitis. The case illustrates the importance of sampling several areas of the pancreas when diffuse enlargement is present on endoscopic ultrasound and multiple masses are seen on cross-sectional imaging.

IgG4-Related Hepatic Pseudotumor Masquerading as a Klatskin Tumor.

Immunoglobulin G subclass 4 (IgG-4)-related disease (IgG4-RD) is an uncommon immune-mediated, fibro-inflammatory disease which has garnered recognition as a systemic condition. One manifestation of the disease in the hepatobiliary system is the development of hepatic inflammatory pseudotumors. These benign tumors are often misdiagnosed as malignant tumors and undergo unnecessary hepatic resections. We present a case of IgG4-related hepatic inflammatory pseudotumor (IPT) mimicking a Klatskin tumor. A high degree of clinical suspicion and extensive workup is imperative in reaching the correct diagnosis. IgG4-related inflammatory pseudotumor is a rare entity, but an important consideration in evaluating hepatic tumors.

An Exceptionally Rare Cause of Refractory Gastrointestinal Bleed: Choriocarcinoma Syndrome.

Testicular choriocarcinomas comprise less than 1% of all testicular tumors and are often highly vascular with early hematogenous metastasis. Choriocarcinoma syndrome (CS) is a rare entity distinguished by diffuse tumor burden and often fatal bleeding from metastatic sites. Most reported cases describe pulmonary hemorrhage secondary to initiation of chemotherapy. We present a fatal case of a young, previously healthy male with overwhelming gastrointestinal bleeding as the presenting sign of CS. Our case demonstrates that CS should be considered in the differential diagnosis for refractory anemia due to gastrointestinal hemorrhage in a young male with a testicular mass.

Persistent Encephalopathy in a Noncirrhotic Patient: Do not Shun This Shunt.

A portosystemic venous shunt is the formation of an abnormal connection between the portal vein and a systemic vein, allowing blood to bypass the liver. Portosystemic shunts are usually believed to be due to portal hypertension in the setting of underlying hepatic disease. We report a case of large, spontaneous intrahepatic portosystemic shunt in a noncirrhotic patient contributing to recurrent hepatic encephalopathy, also known as type B encephalopathy. Management of portosystemic encephalopathy involves occlusion of the shunt by endovascular management.

Reevaluating our understanding of lactulose breath tests by incorporating hydrogen sulfide measurements.

BACKGROUND AND AIM: Breath testing has become a commonly used tool in gastroenterology to evaluate changes in the fermentation pattern of the gut microbiome. Currently, hydrogen and methane gas concentrations are measured in breath testing and evaluated against specific cut-off values for interpretation as normal or abnormal. However, microbial gas kinetics is a complex process that is not currently fully considered when interpreting breath gas results. Gas exchange between hydrogen producers and hydrogen consumers (methanogens and sulfate-reducing bacteria) is a process whereby hydrogen availability is determined by both its production and removal. Hydrogen sulfide is a crucial gas involved in this process as it is a major hydrogen-consumptive pathway involved in energy exchange. METHODS: This is a cross-sectional study evaluating lactulose breath testing with the inclusion of hydrogen sulfide measurements in patients referred for breath testing for gastrointestinal symptoms of bloating, excessive gas, and/or abdominal pain. RESULTS: A total of 159 patients were analyzed between October 2016 and June 2017. Mean hydrogen concentrations with a positive trend through a 3-h period (R 2 = 0.97), mean methane concentrations with a positive trend (R 2 = 0.69), and mean hydrogen sulfide concentrations with a negative trend (R 2 = -0.71) were observed. CONCLUSION: By incorporating energy exchange in the interpretation of the lactulose breath test, we reevaluated specific breath gas profiles, including those commonly described as "hydrogen nonproducers" and the "double-peak" phenomenon.

Rituximab, etoposide, methylprednisolone, high-dose cytarabine, and cisplatin in the treatment of secondary hemophagocytic lymphohistiocytosis with classical Hodgkin lymphoma: a case report and review of the literature.

BACKGROUND: Hemophagocytic lymphohistiocytosis is becoming an increasingly recognized disorder in adults. Classical Hodgkin lymphoma is a relatively uncommon etiology of hemophagocytic lymphohistiocytosis and may complicate treatment options. Rituximab, etoposide, methylprednisolone, high-dose cytarabine, and cisplatin are discussed here as a treatment regimen. CASE PRESENTATION: A 66-year-old Hispanic man previously in good health presented with a 1-month history of recurrent fevers, chills, and night sweats and a 3-week history of new onset jaundice. A bone marrow biopsy revealed a normocellular bone marrow with increased histiocytes with areas of hemophagocytic activity. He met five out of eight criteria for hemophagocytic lymphohistiocytosis diagnosis including fevers, pancytopenia, hemophagocytosis, ferritin of 23,292 ng/mL (>500 ng/mL), and soluble-CD25 of 15,330 pg/mL (>1033 pg/mL). A right cervical lymph node biopsy revealed CD15, CD30, MUM-1, and Epstein-Barr virus-encoded small ribonucleic acid-positive cells with morphologic findings of classical Hodgkin lymphoma, lymphocyte-rich subtype. He completed 2 weeks of hemophagocytic lymphohistiocytosis-directed therapy with etoposide and dexamethasone, but then was switched to rituximab, etoposide, methylprednisolone, high-dose cytarabine, and cisplatin due to minimal improvement in his pancytopenia and hepatic impairment. He completed one full cycle of rituximab, etoposide, methylprednisolone, high-dose cytarabine, and cisplatin with notable improvement in serial hepatic function panels and had an undetectable Epstein-Barr virus viral load. However, he eventually died due to complications of Enterococcus faecalis bacteremia and colonic microperforation in the setting of persistent pancytopenia. CONCLUSIONS: This case discusses the challenges facing treatment of adult malignancy-associated hemophagocytic lymphohistiocytosis. Rituximab, etoposide, methylprednisolone, high-dose cytarabine, and cisplatin may be a viable option for patients with secondary hemophagocytic lymphohistiocytosis and Hodgkin lymphoma who cannot tolerate standard therapies due to hepatic impairment. Targeted therapy and immunotherapy are promising new areas of developing treatments.

A low-cost, rapid deposition method for "smart" films: applications in mammalian cell release.

The "smart" polymer poly (N-isopropyl acrylamide), or pNIPAM, has been studied for bioengineering applications. The polymer's abrupt change in hydrophobicity near physiologic temperatures makes it ideal for use as a substrate in many applications, including protein separation and prevention of biofouling. To tether pNIPAM, many techniques such as plasma deposition, have been utilized, but most are expensive and require long equipment calibration or fabrication periods. Recently, a novel method for codepositing this smart polymer with a sol-gel, tetraethyl orthosilicate (TEOS), was developed. In this work, we adapt this technique for applications in mammalian cell attachment/detachment. In addition, we compare the effects of the pNIPAM/TEOS ratio to functionality using surface analysis techniques (XPS and contact angles). We found the optimal ratio to be 0.35 wt % pNIPAM/TEOS. Cell detachment from these substrates indicate that they would be ideal for applications that do not require intact cell sheets, such as biofouling prevention and protein separation, as this technique is a simple and affordable technique for pNIPAM deposition.