Acute inflammation of the pancreas, known as pancreatitis, can result in many complications ranging from acute distress respiratory syndrome to pancreatic necrosis. A relatively common vascular complication of pancreatitis is splenic vein thrombosis (SVT) due to intimal inflammation leading to platelet aggregation and thrombosis. The management of SVT with regard to anticoagulation (AC) might appear to be perplexing at first given the recommendation to withhold any sort of AC. Research studies have shown that these patients have an increased risk of gastrointestinal bleeding without AC. In this report, we discuss a case of hypertriglyceridemia-induced pancreatitis. During hospitalization, our patient complained of worsening abdominal pain with objective fevers and leukocytosis in which CT scan of the abdomen was significant for hemorrhagic pancreatitis with necrosis, acute SVT, and splenomegaly. The patient was managed conservatively with IV fluids, pain relief medications, and antibiotics.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly infectious viral pathogen with high morbidity and mortality rate. The infection affects multiple organ systems leading to systemic organ failure. There is an increased incidence of acute kidney injury (AKI) in patients who become critically ill. In the critical care setting, the incidence of AKI has been variable amongst different studies. Patients with acute kidney injury who progress to renal replacement therapy are associated with worse outcomes. We describe a case of a 42-year-old male who presented with hypoxemic respiratory failure secondary to SARS-CoV-2 associated pneumonia. The patient was initially managed with the nasal cannula and then required high flow nasal cannula with worsening hypoxemic respiratory failure, requiring invasive mechanical ventilation. On top of worsening respiratory status, the patient developed new onset renal failure requiring hemodialysis.

Actinomycetes are commensal inhabitants of the oral cavity and gastrointestinal tract that can acquire pathogenicity through invasion of injured mucosa. Appendix and ileocecal regions are the most common sites involved in abdominal actinomycosis. We report a case of unusual site actinomycosis, in the recto-sigmoid colon, presenting with abdominal pain and diarrhea after one year of partial sigmoid colectomy. A colonoscopy was done, which showed a 21 mm polypoid partially obstructing mass in the recto-sigmoid colon. Histopathology showed granulation tissue with severe acute inflammation, fibrinopurulent debris with areas of abscess, and branching filamentous organisms with sulfur granules consistent with actinomycosis. Abdominal actinomycosis can infect almost all organs within the abdominal cavity; however, it is more common around the ileocecal region.

Introduction: IgG4 related disease (IgG4-RD) is a newly recognized, immune-mediated disease with IgG4-positive plasma cell infiltration. Serum IgG4 levels are often elevated (although not required for diagnosis). IgG4-RD can affect a multitude of organs, including but not limited to the pancreatic-biliary system, salivary/lacrimal glands, retroperitoneum, liver, aorta, lymph nodes, and rarely, the gastrointestinal tract. This case highlights the rare GI tract presentation of a patient's heretofore unrecognized IgG4 disease. Case Description/Methods: An 81-year-old woman with past medical history of Sjogren's disease, myelodysplastic syndrome, and chronic myelomonocytic lymphoma presented to the emergency department for melena. Physical exam was unremarkable, but melena confirmed on digital rectal exam. Laboratory studies with hemoglobin nadir at 5.0 g/dL (baseline 8), hypergammaglobulinemia (without monoclonal peak) and elevated IgG4. Gastroenterology was consulted and performed esophagogastroduodenoscopy, showing hemorrhagic gastropathy and friable tissue. Biopsy showed gastric mucosa with patchy severe chronic gastritis and predominant plasma cell infiltration (without light chain restriction), thought to be isolated IgG4 gastropathy. Melena resolved with supportive care. Bone marrow biopsy obtained, appropriately decreased cellularity, no monocytes on flow cytometry. Abdominal computerized tomography with intravenous contrast showed diffusely atrophic pancreas, 4.8 cm infrarenal aneurysmal abdominal aorta (AAA), and post cholecystectomy changes. Reported history of pancreatitis (records unavailable), fine needle aspiration of pancreatic head and tail (ten years prior) showed predominantly acute inflammatory cells, necrotic tissue debris and benign ductal epithelial cells, respectively. Salivary gland biopsies (ten years prior) showed benign mucinous gland tissue and multiple reactive lymphoid follicles. The clinical picture was concerning for possible systemic IgG4 disease. Unfortunately, four months after initial evaluation, patient suffered from a cerebrovascular event and passed away a month later after progressive debilitation. Discussion: On initial evaluation, patient appeared to present with isolated IgG4 gastropathy. Given history of salivary gland disease, pancreatic disease, and AAA, high degree of suspicion exists for underlying IgG4-RD connecting previous diagnoses. Although rare, IgG4-RD may present in various ways, and clinicians must remain vigilant for appropriate diagnosis and treatment.

Urinary tract infections are common sources of infections requiring antibiotic use worldwide. Chronic kidney disease (CKD) patients, especially those with minimal urine output are challenging when it comes to antibiotic stewardship given the scarcity of cases in the literature. It is further complicated by the fact that end-stage renal disease (ESRD) patients are found to have asymptomatic pyuria and its clinical significance for bacterial infection is yet to be determined. In this case, we report a patient who presented with nonspecific symptoms including fever, cough, chills, diarrhea, nausea and was found to have left-sided perinephric stranding on CT scan of the abdomen. The patient also had a fever of 104.6 F which we attributed to left-sided pyelonephritis given the high sensitivity of such findings on CT scan. In this report, we explored the literature for the incidence and management of pyelonephritis in ESRD patients who are anuric.

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Reactive thrombocytosis after splenectomy is a feared cause of thrombosis throughout the arterial and venous system. There are many causes of splenomegaly, ranging from cirrhosis to lymphoma to hereditary spherocytosis. In this report, we will discuss a case of reactive thrombocytosis after splenectomy in a patient with hereditary spherocytosis. Splenomegaly is a relatively common finding in HD patients, causing extravascular haemolysis and thus leading to haemolytic anaemia. Splenectomy is usually considered when patients start to manifest severe symptoms such as abdominal pain, jaundice or worsening liver function tests. Our patient was a good surgical candidate and successfully underwent splenectomy but afterwards developed arterial and venous thrombosis due to reactive thrombocytosis. An extensive hypercoagulable work-up was unremarkable. The patient was started on hydroxyurea and anticoagulation with eventual improvement of platelet levels.