Cocaine use is prevalent worldwide and affects multiple organ systems. Ischemia of the esophagus and small bowel are examples of its gastrointestinal complications. Cocaine-induced pancreatitis is a rare entity. Only 8 cases of cocaine-induced pancreatitis have been described in the literature. We present a rare case of a 61-year-old man cocaine user who presented with his first episode of acute pancreatitis (AP) in which common etiologies of AP were excluded. In addition, we explore the pathophysiology of cocaine-induced AP.
Background Vaccination recommendations for childhood cancer survivors are ambiguous. Limited data exist on vaccination rates and patient/caregiver knowledge of vaccination postchemotherapy. Procedure A single‐institution study of childhood cancer survivors treated from 1996 to 2018. Study included a retrospective chart review assessing patient's vaccination status, survey of patient's/caregiver's knowledge/beliefs regarding vaccination postchemotherapy, and assessment of immunoglobulin titers. Results A total of 120 patient charts were included. Vaccination records were available for 82% (98/120) of patients, 57% (56/98) were up to date with vaccinations before chemotherapy, and 83% (81/98) received vaccinations after chemotherapy. Children who resumed vaccination postchemotherapy were younger at cancer diagnosis compared to those who did not resume vaccination (2 vs 4 years, P < .02). Median time since chemotherapy was higher in vaccinated versus unvaccinated patients (107 vs 60 months, P < .02). Immunoglobulin titers were assessed in 27 patients, and 74% (20/27) were not immune to one or more infections tested. Lack of immunity to pneumococcal strains was the most common. There was no difference in median age at diagnosis or time since chemotherapy completion in immune versus nonimmune patients. In 33 surveyed patients/caregivers, 33% (11/33) were not advised about resuming vaccinations postchemotherapy. Over one‐third (12/33) of respondents were concerned about vaccination safety after chemotherapy, although 88% (29/33) agreed they would vaccinate if recommended by their pediatrician/pediatric oncologist. Conclusions Most childhood cancer survivors resume vaccinations postchemotherapy. Considerable variability exists in vaccination timing after chemotherapy. Pediatric oncologists play a central role in educating patients/pediatricians about vaccination recommendations postchemotherapy.
INTRODUCTION: Cocaine-induced pancreatitis is a rare and likely under-reported entity. Physicians must maintain a index suspicion when treating patients with cocaine use who present with abdominal pain especially if they are also on other concomitant medications that increase the risk of acute pancreatitis. CASE DESCRIPTION/METHODS: A 61-year-old male with cocaine abuse and heart failure with reduced ejection fraction (HFrEF) presented with 3 days of epigastric abdominal pain, nausea, and vomiting. His last intranasal use of cocaine was a few days prior to onset of symptoms. Lipase was 2300 (U/L) and computed tomography of the abdomen (CT) demonstrated an edematous and homogeneously enhancing pancreas with a small amount of peripancreatic fluid. Abdominal ultrasound was negative for cholelithiasis. Patient had a remote history of alcohol use but denied recent alcohol abuse. Toxicology was positive for cocaine on day of admission. An ethanol level was not obtained. Triglyceride, IgG4, and calcium levels were within normal limits. Notably, the patient was also hospitalized two months prior to present presentation for new onset left cerebellar stroke. Upon further evaluation, the patient was found to have a left ventricular ejection fraction of 30-35%, consistent with new diagnosis of HFrEF. The patient was started on metoprolol prior to discharge. Based on lack of other identifiable causative factors, patient's pancreatitis was attributed to concurrent cocaine and beta-blocker use. DISCUSSION: Pancreatitis is the most common gastrointestinal diagnosis resulting in admission, costing 2.6 billion dollars annually. The most common etiologies are gallstones and alcohol. Few cases of cocaine-induced pancreatitis have been reported in the literature. Cardiovascular and central nervous system (CNS) toxicities of cocaine such as acute coronary syndromes, chest pain, agitation, and strokes are well documented. Acute gastrointestinal complications of cocaine use are less common however usually include ischemic bowel and related perforation. There are only 5 reported cases of cocaine-induced pancreatitis. The mechanism of action of cocaine is inhibition of noradrenaline re-uptake, which produces vasoconstriction and thrombosis of mesenteric vessels. The pathophysiology of cocaine-induced pancreatitis is postulated to be related to vasoconstriction and thrombotic microangiopathy. In this patient, prior heavy alcohol may have led to underlying parenchymal disease and concomitant use of a beta-blocker were likely additive.
Introduction: Amyloidosis is a rare disease that is defined by deposition of extracellular fibrils from immunoglobulin light chains which results in organ dysfunction. Many patients with primary systemic amyloid have hepatic involvement. Hepatic amyloid deposition is characterized by mild hepatomegaly and occasional elevated liver enzymes. Ultrasound may reveal a heterogenous echogenicity of the liver and Computed Tomography (CT) may reveal decreased parenchymal attenuation. Biopsy is the gold standard for diagnosis, seen as extracellular amorphous material, and Congo red staining will reveal apple-green birefringence under polarized light. Whereas amyloidosis is most often systemic, there are rare cases of isolated hepatic amyloid deposition. Leukocyte cell-derived chemotaxin 2 (ALECT-2) is a novel amyloid subtype, previously thought to be found in renal amyloid with a predominance in Hispanic patients but has recently been reported in the liver. We present a rare case of isolated hepatic amyloidosis without systemic involvement. Case Description/Methods: A 53-year-old Hispanic female with history of diabetes mellitus, hyperlipidemia, and nonalcoholic fatty liver disease presented to hepatology clinic for liver enzyme elevation. Lab studies were significant for AST 36 U/L, ALT 67 U/L, Alkaline Phosphatase, total bilirubin 2.7 mg/dL, positive anti-smooth muscle antibody (22 U), immunoglobulin G 1049 mg/dL, normal anti-nuclear antibody screen and normal anti-mitochondrial antibody. CT showed post cholecystectomy changes, a calcified granuloma in the right hepatic lobe, but otherwise normal liver. Liver biopsy showed focal amyloid deposition, mild steatosis, mild lobular activity, and rare ballooning hepatocytes without fibrosis. Positron emission tomography-CT, bone marrow biopsy, urine and serum protein electrophoresis were unremarkable. Further amyloid testing showed leukocyte chemotactic factor-2 (ALECT-2) amyloidosis. A referral for second opinion and experimental treatment options was recommended, however the patient declined. The patient has had stable lab values over the last two years with observation. Discussion: This is a rare case of isolated hepatic amyloidosis, highlighting the need for maintaining a broad differential diagnosis in a patient presenting with elevated liver enzymes. Given the rare nature of this condition, it is important to demonstrate this patient's presentation and two-year outcomes with observation, given lack of available treatment regimens.
Introduction: Esophageal intramural pseudo-diverticulosis (EIP) is characterized by multiple small outpouches protruding from the esophageal lumen. It is a rare disorder, found in 0.15% of esophagrams. Clinical manifestations include progressive dysphagia, food impaction, and occasionally bleeding. Esophageal strictures are the most common complication of EIP. We present a case of EIP thought to be due to multiple etiologies causing chronic esophageal inflammation. Case Description/Methods: A 55-year old male with a past medical history of alcohol use disorder, recurrent pancreatitis, tobacco use disorder, and hypertension with a recent admission for likely alcohol induced acute pancreatitis presented for a follow up to the clinic. During admission, a CT scan revealed a cystic lesion concerning for an intraductal papillary mucinous neoplasm. A follow up MRI showed a growing cystic pancreatic head lesion, measuring 1.6 cm from 7mm several years prior. He was referred to GI for further evaluation of the pancreatic cyst with endoscopic ultrasound/fine needle aspiration (EUS/ FNA). During his EUS, he was noted to have multiple small pseudo-diverticula in the esophagus and a narrow caliber esophagus so EUS was not performed due to concern for perforation risk (Figure 1). He had no history of dysphagia, odynophagia, weight loss or bleeding. He was also found to have oral candidiasis and started on nystatin swish and spit solution. He was started on a proton-pump inhibitor (PPI) for suspected EIP despite absence of symptoms to potentially prevent progression to stricturing disease. Discussion: Although rare, it is important to identify and closely monitor patients with EIP. The exact etiology is unknown but findings of EIP are linked to chronic inflammatory states. In our patient, chronic alcohol and tobacco use as well as oral candidiasis can contribute to development of EIP. EIP is linked to formation of esophageal strictures causing dysphagia symptoms prompting investigation and treatment with esophageal dilation. Our patient was asymptomatic and EIP was an incidental finding. However, prior studies have shown an increased prevalence of EIP in patients with esophageal carcinoma so close monitoring of patients with findings of EIP is essential. The role of therapies such as PPIs for preventing progression of stricturing disease in EIP is not clear. Further studies are needed to help us better understand this disease.[2454] Figure 1. Multiple esophageal intramural psuedo-diverticuli noted on esophagoduodenoscopy (EGD) (yellow arrows).
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