Multiloculated Liver Abscess Caused by Fusobacterium: Role of Karius Testing in Diagnosis.

Pyogenic liver abscess can be a major diagnostic and therapeutic challenge despite advances in cutting edge technologies. A patient presented with fever, right upper quadrant pain and diarrhea. CT revealed multiple hypodensities in both lobes of liver. The largest lesion was in the left lobe of liver and was multiloculated with thick septations. The causative organism was identified to be Fusobacterium nucleatum by Karius testing. The patient was discharged on six weeks of ertapenem therapy, which resulted in complete resolution. This is the first case of liver abscess where Karius testing was used to identify microorganism. It also highlights that multiloculated and difficult to drain liver abscesses caused by highly sensitive organisms can potentially be treated by intravenous antibiotics alone in immunocompetent patients.

Hyperplastic Gastric Polyp Causing Upper Gastrointestinal Hemorrhage and Acute Blood Loss Anemia.

Hyperplastic polyps are the second most common type of gastric polyp in the United States with equal incidence in both genders, usually found incidentally during endoscopic examinations. It is a well-known fact that they are associated with iron-deficiency anemia due to chronic blood loss. We present a case of a 69-year-old man with a relatively small hyperplastic gastric polyp with acute upper gastrointestinal bleeding, presenting with melena and acute blood loss anemia requiring admission to intensive care unit and urgent endoscopic intervention with hot snare removal of the polyp and cautery of surrounding area with excellent hemostasis. The pathology revealed focal intestinal metaplasia and low-grade dysplasia with no evidence of malignancy. He was subsequently discharged with outpatient follow-up with gastroenterology.

Focal Active Colitis Presented With Chronic Diarrhea.

There are various etiologies of colonic injury and inflammation. The most commonly described colitides in clinical practice are associated with infection, inflammatory bowel disease, ischemia, radiation and medications. The colonic wall has a limited set of responses to different types of injury; therefore, there is overlap between many of these disorders. Focal active colitis is characterized by isolated neutrophilic cryptitis with the background mucosa displaying normal crypt architecture. This inflammatory pattern can be easily unnoticed by pathologists because on low-power examination the mucosa may have almost normal appearance. General practitioners also may not be familiar with this term, underlying etiologies, associated risk factors, course, available therapies and follow up.  We present a case of an 82-year-old female with chronic diarrhea and weight loss. She had a negative infectious workup and normal radiology series. She subsequently underwent endoscopic evaluation in lieu of persistent and debilitating symptoms which revealed nonspecific macroscopic findings with pathology noting focal active colitis. She was empirically treated with a 14-day course of Xifaxan and responded well to management with almost complete resolution of her symptoms and no recurrence on six-month follow-up.

Not All Herbals are Benign: A Case of Hydroxycut-induced Acute Liver Injury.

Dietary supplements do not need prior Food and Drug Administration (FDA) approval before they are sold to the public per Dietary Supplement Health and Education Act of 1994 (DSHEA). Reporting serious dietary supplement related adverse reactions is voluntary. Hydroxycut is a brand of dietary supplements that are marketed as a popular weight loss product that contains multiple herbal constituents. Due to its potential hepatotoxic effects, FDA issued a warning in 2009 and recommended that consumers discontinue use of Hydroxycut. Hydroxycut was recalled from the market but a reformulated herbal mix is now available again. We are presenting a case of acute liver injury associated with Hydroxycut. The prominent pattern of liver injury is severe hepatocellular injury with the striking elevation of the aminotransferase levels and minimal abnormalities in alkaline phosphatase levels. It can sometimes cause severe hepatocellular necrosis.

Most Common Pathway of Metastasis of Rectal Signet Ring Cell Carcinoma to the Skin: Hematogenous.

Liver represents the most common site of metastasis in patients with advanced colorectal cancer (CRC). Cutaneous metastasis is uncommon and has been documented only in 3% of patients. Most cutaneous metastases demonstrate typical histological features of adenocarcinoma, such as glandular formation and mucin production. We present the case of a 66-year-old male with Crohn's disease (CD) and stage IV rectal signet ring cell carcinoma arising in his rectal stump who presented with a painful papular bilateral groin rash. Biopsy revealed metastatic signet ring cell carcinoma. Since cutaneous metastasis in patients with advanced CRC can be easily confused with infection, especially fungal infection, physicians should be vigilant of the possibility of cutaneous metastasis. Our literature review suggests hematogenous spread as the dissemination pathway of this histological subtype of rectal adenocarcinoma to the skin. We present the first case of cutaneous metastatic signet ring cell carcinoma from a rectal stump of a patient with CD.

Diagnosis of Acute Mesenteric Ischemia in a Patient with End-Stage Renal Disease with Normal Serum Lactate.

Acute mesenteric ischemia (AMI) is a life-threatening vascular emergency and a diagnostic challenge for physicians. It represents a group of pathophysiologic processes that have a common end point, that is, bowel infarction, and has a nonspecific clinical picture and a high mortality rate. The most common underlying etiologies are arterial embolism, arterial thrombosis, nonocclusive mesenteric ischemia (NOMI), and mesenteric venous thrombosis. NOMI is caused by prolonged functional vasoconstriction of the visceral arterial vessels, leading to progressive intestinal ischemia, and could be defined by the absence of atherosclerotic thrombotic or embolic occlusion of the mesenteric arteries. The pathophysiology of NOMI remains poorly understood. It can occur in a wide range of critical systemic illnesses associated with hypotension and hypovolemia and in patients on hemodialysis. Elevation of serum lactate may not be present in a significant portion of patients with AMI, which creates an additional obstacle to the prompt diagnosis and often delays treatment. We present a case of a 35-year-old female with HIV and end-stage renal disease on hemodialysis who was admitted for complaints of vague nonspecific abdominal pain. Her initial lactic acid was normal, and due to renal function, she underwent CT of the chest and abdomen without contrast, which only revealed findings consistent with chronic constipation. She later developed vasopressor-dependent hypotension, but her serial lactic acids were all normal. Finally, CT of the abdomen and pelvis was performed with IV contrast, with findings of enterocolitis of the ileum and proximal ascending colon. There was also evidence of pneumatosis involving dilated loops of the small bowel in the lateral mid-abdomen. She underwent an exploratory laparotomy and was found to have gangrene of terminal ileum with associated perforation. Small bowel resection was performed, after which the patient clinically stabilized.

Hydrogen Peroxide Enema-induced Proctitis in a Young Female: A Case Report.

Hydrogen peroxide is a disinfectant commonly used for cleansing superficial wounds due to its oxidizing capacity. In the past, it has also been used for the management of meconium ileus in children as the oxidizing action of hydrogen peroxide potentiates peristalsis that relieves ileus or fecal impaction. The potential dangers were unknown till Pumphrey, in 1951, described the harmful effects of its use as an enema. We present a case of a 32-year-old female who was admitted for complaints of perianal pain. She used an enema, consisting of water and hydrogen peroxide, for constipation. It improved her symptoms but subsequently, she developed a burning sensation in her rectum. The patient had a colonoscopy which revealed severe proctitis up to 15 cm from the anal verge manifested by superficial mucosal ulceration, marked erythema, and edema with friable mucosa and hemorrhage. The patient was subsequently given mesalamine, and the symptoms resolved.