In this inaugural clinicopathological conference, the invited experts discussed the diagnostic approach to central nervous system infections in immunocompromised hosts. The case presented involved a pancreas-kidney transplant recipient with multiple brain abscesses caused by Bartonella henselae. CSF metagenomic next-generation sequencing played a significant role in the diagnosis. Bartonella henselae is a gram-negative zoonotic pathogen that causes cat-scratch disease, which can be transmitted to humans through cat bites or scratches. Symptoms can vary in severity, correlating with the patient's immune status. Visceral organ involvement, ocular involvement, and neurological manifestations have been reported in immunocompromised patients, but brain abscesses are rare.
A 56-year-old man with history of hypertension presented to our clinic for Crohn's disease evaluation. He initially presented to his gastroenterologist with complaints of abdominal cramping and anal discomfort. He had no complaints of fevers, chills, or weight loss. Upon review of his prior history, physical examination and colorectal screening 18 months prior revealed a normal perineum, digital rectal exam, and colonoscopy. His family history is significant for colitis and colon cancer in his mother (both types unknown to our patient). Physical exam at this presentation showed a rubbery textured rectal mass with fistulas on the right buttock. He had no evidence of gross hepatosplenomegaly or adenopathy. MR enterography showed mild hyperenhancement of the rectum without significant rectal wall thickening as well as prominent perirectal and retroperitoneal lymph nodes. This was thought to be mild proctitis without abscess. A repeat colonoscopy was done at which time a polypoid, nonobstructing non-circumferential mass was discovered in the distal rectum. Biopsy showed malignant T-cell lymphoma. Lymphoma of the gastrointestinal tract is the most common type of extranodal lymphoma. However, the etiology remains unclear. Potential risk factors include celiac disease, Helicobacter pylori infection, use of immunosuppressive agents, human immunodeficiency virus, Ebstein Barr virus and inflammatory bowel disease. Colorectal lymphomas are rare and predominantly of B-cell lineage. In our search we found 4 cases reported with primary rectal T-cell lymphoma, the most recent being a primary rectal T-cell lymphoma associated with tubulovillous adenoma. Other reports described rectal T-cell lymphoma in refractory ulcerative colitis, AIDS with Hepatitis C, and at the anastomosis site of adenocarcinoma resection. Common manifestation of colorectal lymphomas are abdominal pain, overt or occult bleeding, diarrhea, intussusception and rarely, bowel obstruction. Our investigation began with a rectal fistula, which is an extremely rare presentation of rectal T-cell lymphoma. This case may help increase awareness of this rare lymphoma and of its even rarer presentations, including rectal fistula.
Durvalumab is approved for the treatment of lung cancer, advanced biliary tract cancers, and is also being evaluated in many other solid organ tumors. The aim of our study is to define the incidence, etiology, and outcomes of liver injury in consecutive patients receiving durvalumab-based immunotherapy.
INTRODUCTION: COVID-19 is a global pandemic. However, the effects of underlying liver disease on COVID-19 in the United States is not well described. We investigated whether COVID-19 was associated with elevations in liver enzymes or hepatic decompensation in patients with underlying hepatic steatosis. METHODS: We retrospectively reviewed the charts of consecutive adults with RT-PCR positive for COVID-19 treated at Michigan Medicine between March 1 and April 30, 2020, who had ultrasound, computed tomography, or magnetic resonance imaging >30 days before COVID-19 diagnosis. Hepatic steatosis was defined based on imaging. Outcomes were: (1) peak ALT or bilirubin following COVID-19 diagnosis, (2) ALT >2 or 5 times upper limit of normal (ULN), defined as the higher of baseline ALT or 19 U/L in women and 30 U/L in men, (3) jaundice defined as bilirubin >2 or 4 mg/dl, and (4) new/worsening ascites or encephalopathy. We conducted regressions with the above outcomes as dependent variables and hepatic steatosis as the primary predictor, adjusting for age, sex, race, recent healthcare exposure, body mass index, hypertension, dyslipidemia, and diabetes. These regression models were logistic for outcomes of abnormal ALT or bilirubin, and linear for maximal ALT or bilirubin. RESULTS: Of patients with prior imaging, 80/159 (50.3%) had steatosis. Overall, 89% of patients were hospitalized, 51% were admitted to intensive care, and 16% died. 14% had chronic liver disease other than NAFLD, 5% had cirrhosis, and 2.7% had prior liver decompensation with ascites, variceal bleeding, or hepatic encephalopathy. Patients with steatosis were older, had higher body mass index, and were more often Black than those without steatosis (Table 1). Baseline ALT and total bilirubin were higher in the steatosis group (Table 1). Hepatic steatosis was associated with increased incidence of ALT >2x ULN (OR 2.93 [1.23–6.97]) or >5x ULN (OR 6.21 [1.45–26.62]), and with peak ALT (beta 39.7 [7.85–71.49]) (Table 2). Hepatic steatosis was not associated with increased bilirubin (Table 2). Rates of new/worsening ascites and encephalopathy were very low: 1.3% and 2.5%, respectively, with no difference based on NAFLD status (P > 0.4 for both). CONCLUSION: Hepatic steatosis is associated with acute hepatocellular injury with COVID-19 infection. Steatosis was not associated with jaundice. Rates of new/worsening ascites or hepatic encephalopathy were very low and unrelated to steatosis status.Table 1Table 2
Case Report An 87-year-old man with a history of diverticular bleed and abdominal aortic stenting presented with 3 episodes of hematochezia. Colonoscopy identified multiple diverticula, including one that was actively bleeding in the sigmoid colon (Figure 1). Two resolution clips were placed in the bleeding diverticulum with hemostasis (Figure 2). Twelve hours later, the patient had recurrent hematochezia. The previously placed aortic stent prevented cannulation of the inferior mesenteric artery by interventional radiology, so a repeat partial colonoscopy was performed without preparation, revealing fresh blood surrounding the 2 previously placed clips. An upper endoscope (Olympus 190 HQ; Olympus, Center Valley, PA) was fitted with a 13.6-mm over-the-scope clip (OTSC®; Ovesco, Tübingen, Germany) that was deployed over the diverticulum and the previously placed clips (Figure 3). The bleeding stopped immediately. The patient did not require surgery and was discharged the next day; he was followed over period of 4 months after discharge and had no further bleeding.Figure 1.: Endoscopic view of the bleeding diverticulum.Figure 2.: Placement of conventional clips with successful primary hemostasis.Figure 3.: OTSC® deployed over the diverticulum and the two conventional clips.Diverticular bleed is the most common reason for lower gastrointestinal bleeding, particularly in older patients. Colonoscopy is considered to be the first-line diagnostic and therapeutic approach, with endoscopic clips generally effective at achieving hemostasis. Rebleeding is common and presents a clinical challenge. In such cases, radiological embolization and surgery are the next interventions; however, they are not without complications.1 The OTSC is a new device designed for mechanical compression and tissue approximation that has been used for complicated GI bleeding, management of perforations and fistulae, full-thickness resection of tumors, and stent anchoring.2 In addition, OTSC has been shown to be an effective method of endoscopic hemostasis for major gastrointestinal bleeding.3 Complications have been reported, including tongue injury as a result of accidental clip deployment in the mouth.4 The use of the OTSC allowed us to achieve hemostasis in our patient without the need for surgery or embolization. Disclosures Author contributions: I. Kassab wrote the manuscript and reviewed the literature. R. Dressner and S. Gorcey edited and reviewed the manuscript. S. Gorcey is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report. Received: April 3, 2015; Accepted: June 2, 2015
Abstract Background Transarterial radioembolization (TARE) is increasingly used as an alternative to transarterial chemoembolization (TACE) for the treatment of hepatocellular carcinoma (HCC). We aimed to perform an overall and individual patient data (IPD) meta‐analysis of studies comparing TACE and TARE. Methods We performed a systematic literature search using pre‐specified keywords with the aid of an informationist for articles from inception to 3/2020. The primary endpoint was overall survival (OS), and the secondary endpoint was time to progression (TTP). Results Seventeen studies met inclusion criteria with 2465 unique patients, with one randomized trial, 4 prospective studies and 12 retrospective studies. Barcelona Clinic Liver Cancer (BCLC) stage B (42.8%) was the most common stage followed by BCLC A (30.3%) and BCLC C (29.0%). There was no difference in OS between the two modalities (−0.55 months, 95% CI −1.95 to 3.05). In three studies with available TTP data, TARE resulted in a longer TTP than TACE (mean TTP 17.5 vs. 9.8 months; mean TTP difference 4.8 months, 95% CI 1.3–8.3 months). IPD‐level meta‐analysis of 311 patients from three studies showed no difference in overall OS between the two modalities including among subgroups stratified by tumor stage and liver function. Limitations of the current literature include inconsistent length of follow‐up, inconsistency in response criteria, and safety reporting. Conclusions Current data suggest TARE provides significantly longer TTP than TACE, although the two treatments do not significantly differ in terms of OS. Given limitations of the current data, there is rationale for prospective studies comparing these modalities.
Background: Novel coronavirus disease 2019 (COVID-19) is a global pandemic with significant morbidity and mortality Possible association between non-alcoholic fatty liver disease (NAFLD) and worse COVID-19 disease progression has been suggested but not well described in the United States We investigated whether COVID-19 was associated with elevations in liver enzymes or hepatic decompensation in patients with underlying hepatic steatosis Methods: We retrospectively reviewed the charts of consecutive adults treated at the University of Michigan for COVID-19 between March 1 and April 30, 2020 Hepatic steatosis was defined based on imaging >30 days prior to COVID-19 diagnosis Outcomes were: (1) peak ALT or bilirubin following COVID-19 diagnosis, (2) ALT >2 or 5 times upper limit of normal (ULN), defined as the higher of baseline ALT or 19 U/L in women and 30 U/L in men, and (3) jaundice defined as bilirubin >2 or 4 mg/dl We conducted regressions with the above outcomes as dependent variables and hepatic steatosis as the primary predictor These regression models were logistic for outcomes of abnormal ALT or bilirubin and linear for maximal ALT or bilirubin Results: Evidence of steatosis on prior imaging was found in 80/159 (50 3%) patients Overall, 89% of patients were hospitalized, 51% were admitted to intensive care unit, and 16% died Chronic liver disease other than NAFLD was found in 14% of patients, 5% had cirrhosis, and 2 7% had prior liver decompensation with ascites, variceal bleeding, or hepatic encephalopathy Patients with steatosis were younger, more often African-American with higher body mass index than those without steatosis Baseline ALT and total bilirubin were higher in the steatosis group Hepatic steatosis was associated with higher incidence of ALT >2x ULN (OR 2 93 [1 23-6 97]) or >5x ULN (OR 6 21 [1 45-26 62]), and with peak ALT (beta 39 7 [7 85-71 49]) Hepatic steatosis was not associated with increased bilirubin Rates of liver decompensation were very low: 1 3% and 2 5%, respectively, with no difference based on NAFLD status (p > 0 4 for both) (Table 1) Conclusion: Analysis from our cohort showed that NALFD is associated with acute hepatocellular injury in patients with COVID-19 Strengths of this study include granularity of data available for review Weaknesses include the observational and single-center nature of the study Larger scale multi-center studies are needed to corroborate these findings (Table Presented)
