Autoimmune hepatitis (AIH) is a chronic inflammation of liver with unclear etiology. It is frequently associated other autoimmune diseases, and its association with celiac disease (CD) is well established. In this article, we describe the case of a 50-year-old male with long-standing AIH taking azathioprine for 10 years, evaluated for flares in transaminases. Despite adding high-dose corticosteroids, his transaminases and bilirubin remained high. Serology for CD was ordered, which revealed elevated tissue transglutaminase antibody IgG and endomysial IgA, which was further confirmed by endoscopic biopsy. Strict gluten-free diet was advised and now for over 2 years he is in remission with azathioprine and budesonide. This emphasizes the role of gluten-free diet in reversing liver dysfunction in patients with AIH, and clinicians should consider screening for CD in patients with AIH with persistent elevation of liver enzymes despite immunosuppressant treatment.
Diphyllobothrium latum (D. latum) infection in humans is uncommon in the United States. Although there has been a drastic decline in the report of D. latum infection in this region, physicians should be aware of an uncommon presentation and its clinical relevance. We report a case of 55-year-old female of Ecuadorian/Peruvian origin who presented with an unknown cause of chronic right lower quadrant abdominal pain for 2 months without other particular symptoms. Initial workup revealed evidence of iron deficiency anemia, and stool occult blood test was positive. She was scheduled for a colonoscopy to assess the source of occult gastrointestinal bleeding. During her bowel preparation, she passed a 25 cm long white tapeworm-like material confirmed microscopically. Despite passing a worm she continued to have abdominal pain. During the colonoscopy, another worm was found lodged in the appendiceal orifice. The colonoscopic images revealed a segmented tapeworm showing contractile motility, approximately 12 cm in length and 6 mm wide in the appendiceal orifice. The scope was unsuccessful in removing the worm. The parasitological and microbiological examination of the passed worm was positive for D. latum. D. latum a fish tapeworm that infects humans after the ingestion of raw or undercooked fish. The patient had a history of often eating lightly marinated raw fish (“ceviche”) in Peru several months before presentation. It is uncommon for D. latum infection to present with iron deficiency anemia. As the worm absorbs approximately 80% of dietary vitamin B12, prolonged D. latum infection usually causes vitamin B12 deficiency and megaloblastic anemia, which is reported to affect about 40% of cases. Abdominal pain related to mechanical obstruction is reported, but this case is unique in that the worm preferentially attached to the appendiceal orifice causing subacute focal appendiceal pain. She was treated with a single dose of oral praziquantel. After the treatment, she developed minor cramping for the next 2 days which resolved by day 3, and recalled passing half-inch sized pieces of white tissue and subsequently improved. Although D. latum infection is an uncommon cause of chronic abdominal pain with iron deficiency anemia, it is crucial to consider because of the potentially treatable outcome.
We have shown that the contact (kallikrein-kinin) system is involved in the pathogenesis of experimental enterocolitis. We now investigate activation of the contact and coagulation pathways, platelets, and neutrophils in active and inactive ulcerative colitis patients as compared to normal controls. In active ulcerative colitis patients, a significant decrease of plasma prekallikrein, high molecular weight kininogen, and C1 inhibitor levels was observed as compared with controls, as well as prekallikrein activation on western blots. Significant elevation of prothrombin fragment (F1 + 2), which indicates thrombin generation, and elastase-alpha 1-antitrypsin complexes, reflecting neutrophil activation, were found in patients with active disease. Plasma beta-thromboglobulin, a marker of platelet activation, was elevated in both active and inactive disease and appears to be a feature of ulcerative colitis. Activation of contact and coagulation pathways, as well as neutrophils, may mediate inflammation in the active phase of ulcerative colitis.
Cronkhite-Canada syndrome (CCS) is a rare non-hereditary disease characterized by chronic diarrhea, diffuse intestinal polyposis and onychodystrophy. We present here a case of a middle-aged female who presented with chronic intermittent bloody diarrhea associated alopecia and loss of finger and toe nails. Labs were remarkable for microcytic anemia and severe hypoalbuminemia. Endoscopy showed numerous polyps scattered throughout the colon. She was treated with nutritional support and corticosteroid with complete resolution of her symptoms and endoscopic findings. CCS is associated with high mortality and gastrointestinal malignancies. Clinicians should consider CCS in a patient with unexplained chronic diarrhea and ectodermal abnormalities.
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