United States

Background: Thyroid storm is a rare condition but life threatening. Having a high index of suspicion is required especially in patients without previous diagnosis of hyperthyroidism. The increasing use of contrasted iodine studies has caused a resurgence of iodine induced hyperthyroidism which in the most severe cases presents as thyroid storm.
Case Presentation: A 21-year-old female presented with 4 weeks of worsening dyspnea. Associated symptoms included abdominal pain, nausea, vomiting and fever. 3 weeks prior to presentation she underwent CT angiogram of the chest which was negative for pulmonary embolism. She had no past medical history and denied any current medications or recreational drugs. Temperature was 98.4 F, heart rate 107 bpm and blood pressure 125/110. On exam she seemed agitated and anxious. Mild exophthalmos, hyperdynamic precordium, tachycardia, and bilateral pedal edema were also present on exam. Labs showed initial TSH 0.00 uIU/mL, elevated free T4 5.3ng/dL and elevated thyroid receptor antibodies. Pregnancy test was negative. She was diagnosed with thyroid storm and treatment initiated with propranolol, hydrocortisone, methimazole and potassium iodide. Later symptoms improved and she was discharged on propranolol and methimazole with plan to follow-up with Endocrinology.
Discussion: Thyroid storm has multisystem involvement which can mimic other conditions such as sepsis leading to delayed diagnosis. Correct diagnosis requires a complete history and physical examination. Use of the Burch-Wartofsky scale is helpful to support diagnosis of thyroid storm; in the case the Burch-Wartofsky score was 40 suggestive of thyroid storm. Looking for precipitating factors is important. These precipitating factors include infection, myocardial infarction, pregnancy, trauma, and large loads of exogenous iodine (contrast or medications like amiodarone). The phenomenon of hypersecretion of thyroid hormone by autonomous areas within the thyroid gland after an acute iodine load is known as the Jod-Basedow phenomenon. It usually develops within 2 weeks of the iodine load. In patients with symptoms suggestive of thyrotoxicosis, exam findings such as thyromegaly/thyroid bruit, or iodine deficiency, it is suggested to request thyroid hormone assay before an iodine contrasted study. 



2022 AMA Research Challenge

The Perfect Storm: Thyrotoxic Crisis Precipitated by Iodinated Contrast

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Abstract Title:Bleeding from Jejunal Diverticula
Background: Small intestinal hemorrhage is a common location of obscure GI bleeding and can be difficult to diagnose and treat given the limitations of traditional gastroscopes and colonoscopes. Jejunal diverticulosis is very rare with the prevalence of 0.3-1.9% in studies of the small bowel and 0.3-1.3% in autopsy studies. The presentation varies from being asymptomatic to causing massive gastrointestinal hemorrhage. We present a case of massive obscure GI bleeding from jejunal diverticulosis that was able to be successfully treated by deep enteroscopy with a pediatric colonoscope.

Case Presentation: 68-year-old female with PMH of internal hemorrhoids, osteoporosis admitted with 3-day history of dark tarry stool, mild epigastric pain, and associated dizziness. She had no significant GI history.
On admission, she was hemodynamically stable. Exam showed melena. Her Hg was 6.5 gm/dL. She was started on IV PPI and received 2 units of PRBCs. Esophagogastroduodenoscopy was performed that showed a 2mm non-bleeding ulcer in the gastric antrum, thought to be the source of bleeding, but no longer active. She was discharged home on oral PPI as Hb was stable
Three days later, she returned to the ED with continued evidence of ongoing blood loss with multiple episodes of melena. Admission Hg was 6.0mg/dL. After initial PRBC transfusion and preparation, colonoscopy was performed that showed pan-diverticulosis, but no active bleeding. Deep intubation of the terminal ileum showed fresh blood, but no active source could be identified, indicating the source was in the proximal small bowel. 
Enteroscopy was then performed with a pediatric colonoscope that showed multiple jejunal diverticula. A visible vessel with active bleeding was seen within a jejunal diverticulum. Hemostasis was successful with clips and hemostatic powder

Discussion: Jejunal diverticulosis is rare and can be congenital or acquired. Prevalence increases with age and most commonly presents in the 6th and 7th decade. The etiology is unclear, but possibly due to small bowel dysmotility with increased intraluminal pressure. It is often asymptomatic but can cause severe complications including hemorrhage, perforation, enterolith formation, small bowel diverticulitis and intestinal obstruction.
Deep enteroscopy should be considered in patients with suspected small bowel bleeding. 



Bleeding from Jejunal Diverticula

Background: Clinical Cases involving ingestion of foreign bodies are very prevalent in the hospital. While most ingested foreign bodies pass spontaneously, sharp objects could become impacted and cause bowel perforation. Upper endoscopy is an established method for retrieving sharp objects in the esophagus. However, when foreign bodies are located beyond the reach of upper endoscope, management becomes ambiguous with limited studies to demonstrate the safety of sharp object removal with colonoscopy. We hereby report a case in which an ingested foreign object adjacent to appendix was successfully retrieved using colonoscopy

Case presentation: A 39 yo/F presented to the ED with RLQ abdominal pain after swallowing the ball portion of her tongue piercing. On examination, abdomen was soft but tender to palpation in the RLQ. No rebound, guarding or signs of peritonitis. CT of the abdomen and pelvis without contrast revealed 1 cm round metallic object in the RLQ without any signs of perforation. Abdominal x ray revealed a round metallic foreign body in the RLQ and benign bowel gas pattern. Colonoscope was advanced to the right colon. Circular, nonimpacted metallic object was located adjacent to the appendix. Circular metallic object was extracted with the assistance of the Roth net retriever. Colonic mucosa was otherwise normal. Patient was observed and subsequently discharged from the hospital without adverse events

Conclusion: This case further demonstrates the effectiveness of colonoscopy in removing foreign bodies from the colon


Endoscopic Retrieval of an Accidentally Ingested Foreign Body

IL-17A plays a significant role in the autoimmune process of Psoriasis. Ixekizumab, a
humanized IgG4 monoclonal antibody inhibits the interaction between the IL-17A and IL-17 receptor, ultimately neutralizing the cytokines and reducing the inflammation in Psoriasis. It is used for other inflammatory diseases like ankylosing spondylitis, non-radiographic axial spondyloarthritis, plaque psoriasis, and psoriatic arthritis. With the increasing use of this medication, we are experiencing a relevant increase in the number of cases of new-onset IBD and IBD exacerbations. So far, no clear association has been shown in the medical literature between Ixekizumab and IBD, and with our compelling case, we want our audience to be aware of this rare association. A 70-year-old female with a past medical history of psoriatic arthritis was started on Ixekizumab 4 weeks ago and presented with a complaint of diarrhea ongoing for three weeks; she had 15-20 bloody stools every day along with abdominal cramping. Diagnostic studies came positive for FIT, ESR 90, CRP 20.13, and CT imaging showed moderate segment mural thickening with peri-colonic fat stranding in the lower descending colon, sigmoid colon, and rectum, indicating either infectious versus inflammatory colitis. GI and ID were consulted, and she underwent a flexible sigmoidoscopy with intestinal biopsies. Biopsies results did not show any infectious causes and were more consistent with inflammatory bowel disease colitis attributed to her recent Ixekizumab usage. The patient responded well to the intravenous methylprednisolone. Discussion IBD is expected to appear in patients with Psoriasis due to the shared genetic causes of these diseases. Biopsies from patients with IBD show higher expression of the IL-17 protein. Patients with Psoriasis have subclinical IBD, which might be unmasked with Ixekizumab by an imbalance caused by the blockade of the IL-17A and the IL-17 receptor. All patients with previously diagnosed IBD should be counseled about this association. Before starting Ixekizumab in psoriatic patients, it is essential to evaluate the gastrointestinal symptoms and specific inflammatory markers like fecal calprotectin. These factors should be monitored to identify early warning signs of the illness and prevent severe complications.

Ixekizumab Causing Inflammatory Bowel Disease

We present the case of a young patient going into hemorrhagic shock due to gastroepiploic artery bleeding after laparoscopic sleeve gastrectomy. Patient was resuscitated and taken back to OR for controlling bleed.

Massive Gastroepiploic Artery Bleed Causing Hemorrhagic Shock After Sleeve Gastrectomy: A Case Report

Background
Mauriac Syndrome is a unique complication of prolonged periods of poor glycemic control in children and adolescents with Type 1 Diabetes Mellitus. Patients present with hepatomegaly secondary to glycogen deposits in the liver. Subsequent hormonal axis disruptions cause short stature and delayed puberty.

Case Presentation
A 15-year-old male with a history of Type 1 Diabetes Mellitus, Celiac Disease, and Growth Hormone Deficiency presented to the Emergency Department with a 5-month history of worsening abdominal pain and distention. He denied fever, weight loss, loss of appetite, emesis, constipation or diarrhea.
Pertinent physical exam findings included generalized abdominal tenderness and hepatomegaly palpable 5 cm below the right costal margin. Weight and height were below the 1st percentile.
Lab findings included Hgb A1c 10.1%, elevated AST 743, ALT 969, Alk Phos 420, GGT 927, Glucose 586, Anion Gap 23.2, UA 4+ glucose/1+ ketones, POC Gas pH 7.3, and HCO3 16.9. Following a normal saline bolus and subcutaneous insulin, his glucose improved to 277, pH 7.4, and HCO3 25.
Imaging revealed an enlarged liver shadow on abdominal x-ray. Ultrasound and MRI of the abdomen confirmed hepatomegaly without masses. Bone Age scan revealed borderline delayed bone age.
He was admitted to the inpatient floor. Endocrinology coordinated his insulin regimen with significant improvement of his hyperglycemia and transaminitis.

Discussion
Mauriac Syndrome should be considered in a pediatric patient with diabetes presenting with hepatomegaly, growth/puberty delay, and short stature. Achieving adequate glycemic control and optimizing an insulin regimen is key to management. With treatment, hepatomegaly resolves, however, growth delays are not easily reversed. Patient education on glucose management and consistent Endocrinology follow up is critical to prevent the development of Mauriac syndrome.

Mauriac Syndrome: Glycogen Hepatopathy in a Pediatric Patient

We describe an immunocompromised individual with chronic diarrhea who developed an acute kidney injury in the setting of chronic Norovirus infection.

A 75 year-old female with cadaveric renal transplant 10 years prior (on immunosuppression) presented with acute right flank pain, worsening fatigue and unintentional weight loss of 80 lbs for over a year. She was tachycardic and hypotensive with a non-tender right lower quadrant renal transplant. Laboratories showed a bicarbonate of 12 mEq/L, blood urea nitrogen of 35 mg/dL, creatinine of 2.4 mg/dL (baseline creatinine 0.9) and white blood cell count of 4.4 K/mcL. Urine studies showed 3+ protein and protein/creatinine ratio of 7,900 mg/g. Tacrolimus level was appropriate. A renal transplant ultrasound was nonspecific, revealing mildly elevated resistive indices measuring 0.8-0.9 suggestive of transplant dysfunction. Serology for Epstein-Barr virus and Cytomegalovirus was negative. Renal biopsy was obtained and was not consistent with either rejection or polyomavirus nephropathy. Patient reported episodes of watery diarrhea. Over the past year, she had painless intermittent diarrhea often requiring hospitalization. A positive stool viral PCR for Norovirus from 6 months ago was discovered on hospital records. Stool studies of C. difficile, Legionella, Shigella, Campylobacter, Salmonella, Cryptosporidium/Cyclospora and Giardia were negative and positive for Norovirus. She was treated with oral immunoglobulin (IG) with a decrease in diarrhea. Her creatinine improved to 1.3.

Norovirus infection may progress to chronic infection after a solid organ transplant. Generally self-limiting, norovirus infection in immunocompromised individuals can lead to prolonged symptoms and viral shedding for many years. Minimal information is available in terms of prevalence of chronic Norovirus infection among solid organ transplant recipients. One study showed a prevalence of 4.6% among solid organ recipients. Of these, 22.8% developed chronic infection, with a median shedding period of 218 days. Currently, there are no approved human antiviral agents that are effective against Norovirus. Treatment using oral IG was extrapolated from its role in management of primary immunodeficiency conditions. In our patient, viral shedding continued but oral IG provided symptomatic relief, decreasing the progression of kidney injury. Physicians should be made aware of this particular presentation and treatment options in renal transplant patients.


Novel Oral Immunoglobulin for Chronic Diarrhea in an Immunocompromised Patient

Background
Post-infantile giant cell hepatitis (PIGCH), also known as syncytial giant cell hepatitis, although a common finding in pediatric cases, continues to be ill-defined with rare disease presentation in the adult population. There have only been 100 reported cases in the last 30 years. Post-infantile giant cell hepatitis is predominantly a histopathological diagnosis, necessitating a tissue sample for the visualization of characteristic giant cell hepatocyte transformation. There is limited literature on the disease process, causes, and treatment success of post-infantile giant cell hepatitis in adults.

Case Presentation
A 41-year-old female with a past medical history of rheumatoid arthritis presented to her gastroenterologist for iron deficiency anemia evaluation and was found to have elevated liver enzymes (AST/ALT). She was asymptomatic with the exception of weight loss. Colonoscopy and fibroscan were non-specific. A subsequent liver biopsy revealed hepatocyte syncytial giant cell change. The correlation of the clinical presentation and histopathology confirmed the diagnosis of post-infantile giant cell hepatitis secondary to rheumatoid arthritis. Interestingly, the patient’s autoimmune hepatitis workup and infectious disease panel were negative. A literature review identified only one case of post-infantile giant cell hepatitis as a secondary manifestation of rheumatoid arthritis. The patient was placed on ursodeoxycholic acid, prednisone, and furosemide, and is currently being managed by hepatology.

Discussion
Our case report aims to bring forth a vignette of post-infantile giant cell hepatitis to spotlight this ill-defined disease and highlight some of the proposed causes, treatments, and laboratory markers. Post-infantile giant cell hepatitis is thought to be a secondary manifestation of other disease processes, including viral, autoimmune, hematologic, or drug-induced injury. It can also be idiopathic in nature. Management of PIGCH largely depends on the underlying mechanisms; thus, treatment is patient-specific. Our case showing PIGCH’s association with rheumatoid arthritis provides valuable insight into the future diagnosis, treatment, and understanding of this rare disease and its association with autoimmune diseases in adult populations.

Post-Infantile Giant Cell Hepatitis Associated with Rheumatoid Arthritis

Background
Percutaneous endoscopy gastrostomy (PEG) tube placement is commonly performed in patients with functional gastrointestinal tracts but inability to maintain adequate oral intake. Mortality due to PEG tube placement is <1%; however minor and major risks exist including infection and intrabdominal organ injury.

Case Presentation
A 35-year-old man with history of Down Syndrome and Type 2 Diabetes was admitted with COVID-19 pneumonia. He initially required intubation and underwent tracheostomy two weeks into admission. Respiratory status stabilized, and he was evaluated for a PEG tube to continue tube feeds. History from the patient’s family member revealed that the patient briefly had a feeding tube as a child. The consulting Gastroenterology service evaluated the patient and did not deem the prior procedure a barrier to PEG tube placement. The patient had a normal upper endoscopy, and a gastrostomy tube was placed via transillumination. Tube feeds were initiated with advancement to bolus feeds well-tolerated. However, one week after PEG tube placement, he reported intermittent chills, myalgias, and fevers up to 103 F with leukocytosis to 18,000/μl. Abdominal exam was notable for slight distention but no guarding or rigidity. CT of the abdomen and pelvis showed the PEG tube traversing the left hepatic lobe enroute to the stomach and a consequent 3-centimeter intrahepatic fluid collection. Patient was emergently taken for laparoscopic revision and drainage of the fluid collection. With operative management and appropriate antimicrobial therapy, his symptoms fully resolved.

Discussion
Liver injury from PEG tube placement is a rare complication with a patient presentation that can range from asymptomatic to critical illness. There are less than twenty cases documented in the literature. Prior abdominal surgery or PEG tube can increase the risk of intraabdominal injury. Awareness of risks associated with the procedure can facilitate early recognition and definitive management of a potentially life-threatening complication.

Rare Complications: Hepatic Injury Following PEG Tube Placement

Stercoral colitis is a rare condition that occurs secondary to the impaction of fecal matter in the colon, leading to distention, bowel wall edema, ulceration, ischemic colitis and ultimately, bowel perforation. Most cases are seen in elderly patients with dementia, chronic opioid users, and patient with neuropsychiatric conditions. Here we present a case of a patient with multiple comorbidities who developed Stercoral colitis.
A 52-year-old female with medical history of Diabetes Mellitus, Hypertension, Chronic Kidney Disease, Bipolar Disorder, on methadone for chronic opioid use disorder that was receiving inpatient care for a left foot osteomyelitis. The patient showed a labile mood and hostile behavior towards medical staff throughout hospitalization. Intermittently refused medical treatment and routine evaluations. She complained of abdominal discomfort but refused to speak and provide further details upon interrogation. History taking and physical examination were limited due to her uncooperative behavior. Laboratory workup showed no electrolyte or metabolic disturbances. Abdominal X-ray was remarkable for changes consistent with severe constipation. Due to persistent abdominal pain, an Abdominopelvic CT scan was performed for further assessment. It showed a distended rectum with fecal impaction and associated stercoral colitis. The patient was educated about complications concerning diagnosis, and treatment options were discussed with the patient. Treatment included daily mineral oil enemas and digital fecal disimpaction. She was reluctant to cooperate with proposed therapy at first. We consulted with psychiatry service to optimize psychiatric medications. With time, the patient became more cooperative and receptive to medical therapy. Fecal impaction resolved, and symptoms improved. The patient was safely discharged to a rehabilitation facility.
Stercoral colitis is under-documented in the medical literature; therefore, awareness of the condition and recognizing signs and symptoms of this potentially fatal condition is imperative. Comorbidities may delay the diagnosis by preventing optimal history taking and masking physical examination. This case also highlights the importance of an interdisciplinary team when caring for a complex patient.

Stercoral Colitis: A feared complication of a common complain.

Background
An allergy to mammalian meat and its derived projects due to an IgE antibody to galactose-alpha-1,3-galactose. In the United States, almost exclusively due the tick bite of Amyblyomma Americanum, The Lone Star tick. The allergy to only be limited to red meat, but the epitope of the antigen has been increasingly found in an increased food. Amblyomma Americanum is found most prevalently in the Southeastern United States. 3-6 hours after eating red meat (e.g. beef, lamb), patients begin to suffer integumentary symptoms such as rash, hives, or swelling, GI symptoms such as vomiting or cramping, respiratory symptoms such as wheezing, SOB, stridor, throat clearing, or hypotension
Case Presentation
We report 3 cases of pediatric patients who present with only non-anaphylactic symptoms of Alpha-gal syndrome. A nine-year old female presented to the peds GI clinic with 4.5 year history of progressively worsening abdominal pain, emesis, and diarrhea with no relief from Prevacid or Lansoprazole. Normal PEx, CMP, CBC w/ diff., EGD, and negative celiac. A14 yo F presented to Peds GI clinic w/ 4 year history of diarrhea, nausea, and abdominal pain, uncontrolled by Ranitidine, Zantac, and Prilosec. Normal US, HIDA Scan PEx, CBC w/ diff, CMP, EGD, negative H. Pylori and pregnancy test. 6 yo M presented to Peds GI clinic with history of chronic, intermittent abdominal pain, constipation, and dyschezia. Eliminated gluten and dairy, which led to transient symptom relief, but did not persist. Normal PEx, CBC w/diff., CMP, TSH, negative celiac. 
Discussion
The patients observed in this study were of varying ages and had a different set of symptoms, whether it be emesis, diarrhea, or constipation, with the only commonality being abdominal pain
Regardless of their backgrounds, when these patients were found to have an elevated alpha-gal IgE test and to go a meat avoidance test, their abdominal pain and most of their symptoms globally resolved. Some of these patients had abdominal symptoms to foods such as ice-cream; carb moiety galactose-alpha-1,3-galactose is present in cow’s and goat’s milk, which can appear as a milk intolerance. These patients took on average at least 2-3 years to diagnose, given that they did not have delayed anaphylaxis.


The Perfect Storm: Thyrotoxic Crisis Precipitated by Iodinated Contrast

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