Case Study

  • Case Study |

    Epstein–Barr virus (EBV) infection with gastrointestinal tract involvement is extremely rare in immunocompetent adults. This Case Study describes an immunocompetent 30-year-old man who presented with several months of bloody diarrhea and cramping abdominal pain, suggestive of IBD. However, viral serologic tests confirmed acute EBV infection, and EBV-associated lymphoproliferative disorder of B-cell lineage with diffuse colonic involvement was diagnosed.

    • Jordan J. Karlitz
    • , S. Tammy Li
    • , Robert P. Holman
    •  & Matthew C. Rice
  • Case Study |

    This article discusses the case of a 63-year-old woman who presented with dysphagia 27 years after she received radiation therapy for Hodgkin disease. She was diagnosed with a large tracheoesophageal fistula and poorly differentiated squamous cell carcinoma of the esophagus. The authors describe, for the first time, successful surgical management of this complex clinical condition.

    • Jeroen Hagendoorn
    • , Marguerite E. I. Schipper
    • , Arjan Cloïn
    • , Faiz Z. Ramjankhan
    • , Peter D. Siersema
    •  & Richard van Hillegersberg
  • Case Study |

    A 37-year-old female was given esomeprazole to treat reflux-like dyspeptic symptoms 3 years after undergoing surgery for a neuroendocrine pancreatic neoplasm. During esomeprazole treatment, her serum chromogranin A level rose to around three times the upper limit of normal, but her gastrin levels remained in the normal range. Relapse of the neuroendocrine tumor was suspected; however, investigations led to a diagnosis of esomeprazole-induced hyperchromograninemia in the absence of elevated levels of fasting serum gastrin.

    • Giovanni Gori
    • , Giacomo Spinelli
    • , Claudio Spinelli
    • , Marco Tuccori
    • , Corrado Blandizzi
    •  & Mario Del Tacca
  • Case Study |

    A 38-year-old female was evaluated for a 3 year history of postprandial abdominal pain, refractory nausea, vomiting and hematemesis. Her medical history was significant for juvenile polyposis syndrome and Crohn's disease resulting in a total colectomy. Juvenile polyposis syndrome with outlet obstruction of the stomach and excessive hypergastrinemia was diagnosed and treatment started with acid suppressive therapy, prokinetic therapy and total parenteral nutrition. Repetitive endoscopic polypectomy (also known as debulking) was performed twice followed by gastrectomy with duodeoesophageal anastomosis.

    • Karen D. Papay
    • , Vincent G. Falck
    • , Steen S. Poulsen
    • , Remo Panaccione
    • , Jens F. Rehfeld
    •  & Martin A. Storr
  • Case Study |

    This article considers the case of a 72-year-old woman who presented with a 2-month history of right upper quadrant abdominal pain and a 15-day history of jaundice. The patient was diagnosed with bile duct duplication and coexistent cholangiocarcinoma. This Case Study explores the diagnosis and management of this patient and is believed to be the first reported case in the literature of this unique variant of bile duct duplication.

    • Ilkay Kosar
    • , Hilmi Ataseven
    • , Özlem Yönem
    • , Erol Çakmak
    • , Özdemir Özer
    • , Hatice Özer
    •  & Ömer Topçu
  • Case Study |

    A 72-year-old man was evaluated for dysgeusia, diarrhea and ano-rexia. 3 months earlier he began to experience taste changes, a de-cline in appetite and 3–7 loose, non-bloody stools per day, followed by nausea, lower abdominal cramping and weight loss of 22.68 kg. Cronkhite–Canada syndrome was diagnosed and treatment started with prednisone, a histamine-2-receptor blocker and oral micronutrient supplementation. All visible polyps were removed and subtotal colectomy with end-to-side ileorectostomy per-formed.

    • Seth Sweetser
    • , Glenn L. Alexander
    •  & Lisa A. Boardman
  • Case Study |

    A 33-year-old woman with a history of paroxysmal nocturnal hemoglobinuria (PNH) presented with abdominal pain, nausea and vomiting, accompanied by duodenal wall thickening seen on an abdominal CT scan and an ischemic-looking duodenal mucosa as visualized by endoscopy. She was diagnosed as having small bowel ischemia complicating PNH. Treatment with warfarin was started, but ischemic episodes recurred. Treatment with eculizumab was, therefore, proposed. This case highlights this rare gastrointestinal complication of PNH.

    • Joana Torres
    • , Bénédicte De Vroey
    • , Marie-Pierre Noël
    • , Bertrand Notteghem
    •  & Jean-Frédéric Colombel
  • Case Study |

    A 50-year-old man from Las Vegas with a history of complicated Crohn's disease and who had received adalimumab therapy presented with left lower quadrant abdominal pain, periorbital headache, blurry vision, tinnitus, polydipsia, right elbow pain and weight loss. He was diagnosed with having disseminated coccidioidomycosis. Despite antifungal treatment, surgical debridement and irrigation, and discontinuation of immunosuppressive therapy, the patient eventually died. This case highlights the risk of developing endemic mycoses while receiving biologic therapy.

    • Sumeet S. Mitter
    • , Ariss DerHovanessian
    • , Joseph D. Hillman
    •  & Daniel Z. Uslan
  • Case Study |

    This article considers the case of a 17-year-old adolescent with a history of Crohn's disease who was receiving infliximab and presented with a new-onset rash. The rash did not resolve with corticosteroid treatment and worsened after further treatment with infliximab and also after subsequent administration of adalimumab. He was diagnosed as having an anti-TNF agent induced psoriasiform rash. The rash resolved after discontinuation of anti-TNF agents and his rash has not recurred during 3 years of follow-up.

    • Laurie S. Conklin
    • , Bernard Cohen
    • , Lindsay Wilson
    • , Carmen Cuffari
    •  & Maria Oliva-Hemker
  • Case Study |

    This article considers the case of a 58-year-old man with a history of type II diabetes, obesity and hypertension who presented with non-alcoholic steatohepatitis-related liver cirrhosis and hepatocellular carcinoma (HCC), and self-referred for a second opinion. He was diagnosed with unresectable HCC. The patient underwent radioembolization with Yttrium-90 glass microspheres, which substantially decreased the tumor mass. 1 year after initial diagnosis with HCC the patient underwent orthotopic liver transplantation (OLT). He remains negative for recurrence of HCC 2.5 years post-OLT.

    • Laura E. Moreno Luna
    • , Paul Y. Kwo
    • , Lewis R. Roberts
    • , Teresa A. Mettler
    • , Denise N. Gansen
    • , James C. Andrews
    • , Gregory A. Wiseman
    •  & Vijay Laxmi Misra
  • Case Study |

    This article considers the case of a 49-year-old woman with a history of hepatitis C and peptic ulcer disease who presented with massive hematemesis. She was diagnosed with gastric variceal hemorrhage and splenic vein thrombosis. The patient underwent splenic artery embolization and balloon-occluded retrograde transvenous obliteration of gastric varices. By 30 months post-treatment no evidence of gastric varices or splenic vein thrombosis remained.

    • Vanessa Tieu
    • , George Behrens
    • , Hector Ferral
    • , Stanley M. Cohen
    •  & Joseph Ahn
  • Case Study |

    Clostridium difficile infection is increasingly recognized in patients who have undergone restorative proctocolectomy with ileal-pouch–anal anastomosis. The effect of this infection on patient outcomes is not clear. In this Case Study, Shen and colleagues describe a case of fulminant C. difficile-associated pouchitis with a fatal outcome that occurred after ileostomy closure.

    • Bo Shen
    • , Feza H. Remzi
    •  & Victor W. Fazio
  • Case Study |

    This article considers the case of a 58-year-old man who presented with a 35-year history of Crohn's disease, pararectal fistulas and abscess formation. He had been taking azathioprine therapy for approximately 5.5 years. He was started on infliximab; however, his fistulas persisted and the abscess recurred. He was, therefore, switched to adalimumab. After development of pancytopenia, a bone marrow biopsy and a diagnostic splenectomy were performed, leading to a diagnosis of hepatosplenic T-cell lymphoma.

    • Florian Beigel
    • , Matthias Jürgens
    • , Cornelia Tillack
    • , Marion Subklewe
    • , Doris Mayr
    • , Burkhard Göke
    • , Stephan Brand
    •  & Thomas Ochsenkühn
  • Case Study |

    This article considers the case of a 49-year-old man who presented with fatigue and poor concentration. He was diagnosed with HCV genotype 1 infection and started on a 48-week course of pegylated interferon α2b plus ribavirin. Despite initial reductions in his serum HCV-RNA levels, HCV-RNA remained detectable at week 12; however, it was undetectable by week 24. The patient was classified as a slow responder and therapy was extended to 72 weeks.

    • Paul J. Gaglio
  • Case Study |

    This article considers the case of a 66-year-old white man who presented with a productive cough and pleuritic chest pain on his right side 6 months after undergoing transarterial chemoembolization for hepatocellular carcinoma. The patient was diagnosed with a biliopleural fistula, and this Case Study explores the diagnosis and management of this patient.

    • Jeffrey R. Lewis
    • , Helen S. Te
    • , Brian Gehlbach
    • , Aytekin Oto
    • , Jennifer Chennat
    •  & Smruti R. Mohanty
  • Case Study |

    This article considers the case of a 73-year-old white man who presented with synchronous gastric carcinomas and a 20-year history of mixed polyposis. Genetic-testing and molecular-pathology analyses confirmed a diagnosis of Cowden's syndrome. The case explores the diagnostic challenges of differentiating between hamartomatous and adenomatous polyposis syndromes in patients with mixed polyposis, and emphasizes the need to characterize the risk of gastrointestinal cancer in patients with this syndrome.

    • Khalid Al-Thihli
    • , Laura Palma
    • , Victoria Marcus
    • , Matthew Cesari
    • , Yael B Kushner
    • , Alan Barkun
    •  & William D Foulkes
  • Case Study |

    In this Case Study, Schnitzbauer et al. describe the case of a 30-year-old male who suffered multiple fractures and extensive internal injuries, including liver rupture with formation of a hematoma, because of a motorcycle accident. While in intensive care, the hepatic hematoma became infected with antibiotic-resistant bacteria and serum levels of cholestatic parameters started to increase, until retrograde cholangiography supported a diagnosis of cholangitis in a critically ill patient. Acute liver failure ensued, and liver transplantation carried out. In spite of a number of intervening complications, 50 months after transplantation the patient was in good health; therefore, the authors conclude that post-traumatic sclerosing cholangitis should probably become an indication for liver transplantation.

    • Andreas A Schnitzbauer
    • , Tung-Yu Tsui
    • , Gabriele Kirchner
    • , Marcus N Scherer
    • , Thomas Bein
    • , Hans J Schlitt
    •  & Aiman Obed
  • Case Study |

    This Case Study considers a 51-year-old male who developed unilateral hearing loss while taking pegylated interferon and ribavirin for the treatment of chronic hepatitis C infection. The patient was treated with prednisone and continued with his antiviral therapy. Improvement in the patient's hearing was achieved within a few days, and full recovery was achieved within 2 months.

    • Vu Le
    • , Ted Bader
    •  & Javid Fazili
  • Case Study |

    This article considers the case of a 72-year-old male who presented with epigastric pain, anorexia and progressive jaundice. Liver function tests revealed enzyme abnormalities consistent with cholestasis, while radiographic and endoscopic findings were suggestive of autoimmune pancreatitis with biliary involvement. Examinations for the presence of malignant cells were negative. A diagnosis of autoimmune pancreatitis with IgG4-associated cholangitis was made and the patient was treated with corticosteroids.

    • Aaron J Small
    • , Conor G Loftus
    • , Thomas C Smyrk
    •  & Todd H Baron
  • Case Study |

    This article discusses the 11-year case history of a 13-year-old girl who presented with vomiting, abdominal pain and distension with evidence of small-bowel obstruction. Over the years, numerous laparotomies were performed for recurrent abdominal symptoms, which were managed with intravenous fluids, bowel rest and nasogastric decompression of the upper gut. After a diagnosis of primary visceral myopathy was made, prokinetic agents were prescribed and a venting gastrostomy inserted for decompression. Total parenteral feeding was initially used to maintain nutrition but was ceased when her symptoms improved.

    • Lisa SE Shim
    • , Guy D Eslick
    • , Alex E Kan
    •  & Jamshid S Kalantar
  • Case Study |

    This article considers the case of a 19-year-old white woman who presented with a 6-month history of progressively worsening dysphagia. Eosinophilic esophagitis was diagnosed and a PPI and fluticasone propionate prescribed; fluticasone propionate was tapered, but the PPI maintained. When dysphagia returned, fluticasone propionate was restarted, but rapidly progressive dysphagia with severe chest pain and odynophagia developed. A diagnosis of herpes esophagitis with concurrent eosinophilic esophagitis was made, fluticasone propionate treatment immediately discontinued and fluconazole and valaciclovir prescribed.

    • Guy M Lindberg
    • , Richard Van Eldik
    •  & Mohammad H Saboorian
  • Case Study |

    This article considers the case of a 62-year-old white woman who presented with a 2-month history of progressive, painless, left supraclavicular and axillary lymph node enlargement. Her history was significant for chronic HCV infection, for which she had just completed a 48-week course of treatment with pegylated interferon [alpha] plus ribavirin. Granulomatous lymphadenitis with sarcoid and tuberculoid granulomas was diagnosed and anti-tuberculosis treatment initiated with a successful outcome.

    • Carlos Noronha Ferreira
    • , Elidio R Barjas
    • , Luis A Correia
    • , Luis Tavares
    • , Cristina Ferreira
    • , Fatima L Serejo
    • , Miguel Carneiro de Moura
    •  & Estela Monteiro
  • Case Study |

    This article considers the case of a 54-year-old male with a history of coronary artery disease, diabetes mellitus and tobacco abuse who presented with right upper quadrant abdominal pain, decreased appetite and jaundice. After admission, the patient's clinical status declined rapidly, with the development of confusion, respiratory failure, hypotension, renal failure and worsening lactic acidosis. The patient developed asystole and was pronounced dead on hospital day 4.

    • Jeffrey Gilbert
    • , Heather Rutledge
    •  & Alvaro Koch
  • Case Study |

    This Case Study considers a 56-year-old female with a 2-week history of fevers, chills and right upper quadrant pain. Her medical history was significant only for hypertension. She denied high-risk sexual behavior, the use of tobacco, alcohol or illicit drugs, had no sick contacts and had not traveled recently, but she had adopted a stray cat 1 month before presentation.

    • Jared Hossack
    • , Paul Ricketts
    • , Helen S Te
    •  & John Hart
  • Case Study |

    This Case Study describes a female with ileocolic Crohn's disease who was taking immunosuppressive therapy who presented with a 1-month history of bloody diarrhea, decreased caliber of stools, a broad indurated perianal fissure as well as a deep palmar space abscess. The patient was diagnosed with disseminated histoplasmosis. The authors of this article discuss the diagnosis and management of this patient and the importance of considering histoplasmosis in patients on immunosuppressive therapy who develop atypical symptoms.

    • Susan Galandiuk
    •  & Brian R Davis
  • Case Study |

    This Case Study considers a 20-year-old female with a history of Crohn's colitis, perirectal abscesses and fistulizing disease who developed painful erythematous nodules in her pretibial region. She was on no medications for her Crohn's disease because of medication side effects and intolerance. Active Crohn's disease with perianal fistula and sigmoid colitis and erythema nodosum were diagnosed and treatment with adalimumab initiated.

    • Alissa Quin
    • , Sunanda Kane
    •  & Olga Ulitsky
  • Case Study |

    This Case Study discusses a 57-year-old male diagnosed with an aortoenteric fistula secondary to aortic graft surgery. The case highlights the importance of performing multidetector CT as soon as possible in patients who are suspected to have this condition so a quick diagnosis can be made.

    • Bülent Ödemiş
    • , Ömer Başar
    • , İbrahim Ertuğrul
    • , Mehmet İbiş
    • , İlhami Yüksel
    • , Engin Uçar
    •  & Kemal Arda
  • Case Study |

    This article considers the case of a 22-year-old female with congenital disorder of glycosylation type Ib and a history of congenital hepatic fibrosis, portal hypertension and esophageal varices, who presented with edema, diarrhea, hypoalbuminemia and pancytopenia. Protein-losing enteropathy was diagnosed. As previous mannose therapy was associated with diarrhea and abdominal pain, albumin was infused followed by intravenous and subcutaneous therapy with unfractionated heparin.

    • Ylian S Liem
    • , Lars Bode
    • , Hudson H Freeze
    • , Frank WG Leebeek
    • , Adrienne AM Zandbergen
    •  & JH Paul Wilson
  • Case Study |

    This Case Study describes a 72-year-old male who had an unresectable adenocarcinoma of the pancreas and enrolled in a clinical trial of endoscopic ultrasound-guided neoadjuvant therapy to downstage the tumor. The tumor was surgically removed with a complete pathologic response and showed no signs of recurrence at the 12-month follow-up, although the patient went on to develop bilateral pulmonary nodules and a liver mass, consistent with metastatic disease.

    • Kenneth J Chang
    • , John G Lee
    • , Randall F Holcombe
    • , Jeffrey Kuo
    • , Raman Muthusamy
    •  & Mark L Wu
  • Case Study |

    This Case Study describes a 40-year-old female laboratory technician who accidentally came into contact with water containing snails infected with Schistosoma mansoni. Cercarial dermatitis occurred in the areas exposed to the contaminated water, but a unique treatment approach involving a single oral dose of oxamniquine (50 mg/kg) on the day of exposure resulted in cure during the early stages of disease. No further symptoms were observed throughout follow-up.

    • Martin J Enk
    • , Naftale Katz
    •  & Paulo Marcos Zech Coelho
  • Case Study |

    This Case Study describes a 47-year-old woman who was treated with indomethacin for osteoarthritis-related hip pain. Soon after beginning treatment she developed nausea, vomiting, abdominal pain, dark urine and jaundice. Despite discontinuing all medications, her symptoms worsened. Treatment with prednisone 40 mg/day was initially successful, but after tapering (over 18 months) and then discontinuing prednisone her liver chemistry test results worsened and a liver biopsy showed evidence of chronic hepatitis.

    • Clara Abraham
    • , John Hart
    • , Susan M Locke
    •  & Alfred L Baker
  • Case Study |

    This Case Study describes a 45-year-old white female who was admitted to hospital with a 1-week history of right upper quadrant abdominal pain, progressive tiredness and jaundice. Test results raised concerns that the she had a concomitant acute onset of HCV and autoimmune hepatitis, necessitating liver biopsy. The patient was diagnosed with acute symptomatic infection with HCV genotype 1a with no evidence of autoimmune hepatitis.

    • Wayne Tsuang
    • , Ram Subramanian
    • , Qiang Liu
    • , John Hart
    •  & Smruti R Mohanty
  • Case Study |

    This Case Study discusses a 39-year-old man who initially presented with a 2-month history of abdominal pain, jaundice, non-bloody diarrhea, weakness and weight loss. Vanishing bile duct syndrome and IBD, type unclassified, were diagnosed. Budesonide therapy improved the patient's symptoms, but they worsened several months later. Repeat evaluation revealed extensive lymphadenopathy and an elevated white blood cell count, and Hodgkin's lymphoma was diagnosed.

    • Anthony T DeBenedet
    • , Carl L Berg
    • , Kyle B Enfield
    • , Randall L Woodford
    • , Audrey K Bennett
    •  & Patrick G Northup
  • Case Study |

    This Case Study describes a 17-year-old boy who presented with sudden onset of visual impairment, identified as bilateral anterior uveitis by an ophthalmologist. The patient was diagnosed with multifocal Crohn's disease, involving the terminal ileum, cecum, stomach and duodenum. The authors discuss the importance of rapid evaluation of extraintestinal manifestations of Crohn's disease.

    • Marc Girardin
    • , Kevin A Waschke
    •  & Ernest G Seidman
  • Case Study |

    This Case Study describes a 24-year-old white male with Crohn's disease that was in remission who presented with cholestasis and hyperbilirubinemia. The patient had normal alanine aminotrasferase and γ-globulin levels, and the results of serological tests for an infectious cause of hepatopathia were negative. The patient was diagnosed with autoimmune hepatitis–primary sclerosing cholangitis overlap syndrome on the background of primary sclerosing cholangitis.

    • Leif E Sander
    • , Alexander Koch
    • , Carsten Gartung
    • , Ron Winograd
    • , Andreas Donner
    • , Axel Wellmann
    • , Christian Trautwein
    •  & Andreas Geier