This case presents a patient with a history of non-small cell lung carcinoma who had radiation therapy complicated by esophageal dysphagia. She had a fully covered self-expanding metal stent (SEMS) placed one year ago in the proximal region of her esophagus prior to this admission. She presented to the emergency department (ED) for dyspnea on exertion. Imaging showed a persistent right lower lobe opacity, and bronchoscopy revealed a right broncho-esophageal fistula (BEF). Further investigation by endoscopy found that the fully covered SEMS migrated distally and caused the formation of her fistula. This case presents a patient with a right BEF caused by a migrating esophageal stent.
Figure 1. Top: CT and MRCP showing gallbladder distension. Bottom: Pathology showing invasive mucinous adenocarcinoma.Table 1. WBC 5 White blood cells Hgb 5 hemoglobin BUN 5 blood urea nitrogen AST 5 aspartate transaminase ALT 5 alanine transaminase INR 5 international normalized ratio Admission Normal Range WBC 7.1 K/mcL 3.4 -11 K/mcL Hgb 12.6 g/dL 11.9 -15.3 g/dL Platelets 182 K/mcL 150 -425 K/mcL
These values were a significant increase from normal the month before. This necessitated up-titration of prednisone and MMF, which normalized her liver enzymes within two months. A 67-year-old female with a past medical history of hypothyroidism was found to have elevated liver enzymes associated with fatigue. Further lab work-up and liver biopsy revealed autoimmune hepatitis. This patient's autoimmune hepatitis was controlled on a regimen of prednisone and MMF for six months. However, three weeks after receiving the third COVID Pfizer vaccine, this patient's labs exhibited AST: 99 and ALT: 105. These values were a significant increase from normal the month before. Her immunosuppressants were up-titrated with an increase in MMF and the addition of cyclosporine. Her labs improved to AST: 73 and ALT: 87 within two months. Discussion: These cases demonstrate that COVID vaccination may play a role in autoimmune hepatitis flares. This can be a challenging situation for many clinicians to navigate, as COVID remains a significant threat to patients' health, and there are many case reports that show that COVID infection itself can precede a flare. Patients with autoimmune liver disease may benefit from closer laboratory evaluation surrounding COVID vaccination.
Introduction: Opportunistic infections are fearful complications usually observed in immunocompromised patients. Esophagitis with Candida, HSV and CMV is among those infections, but infections with 2 organisms simultaneously is uncommon and can be missed leading to complications. We are presenting a case with concomitant HSV and candida esophagitis in a patient with achalasia. Case Description/Methods: A 65-year-old male with PMH of Barrett's esophagus, achalasia, GERD, stage IV prostate cancer on chemotherapy with docetaxel and on chronic steroids for metastatic bone pain. He had trouble swallowing for many years, had manometry as an outpatient and was diagnosed with type 1 achalasia. For that he underwent endoscopic dilatation in the past. He presented with worsening odynophagia and dysphagia for the last 3 days to the extent that he was unable to swallow his own saliva. He underwent EGD which showed extensive esophageal plaques consistent with candida (Figure A), biopsies were taken. He was started on IV Fluconazole. Pathology of biopsies with PAS and GMS stains demonstrated infiltrating hyphae and yeasts, confirming esophageal candidiasis (Figure B). In addition biopsies also revealed viral inclusions, multinucleation and molding, with immunohistochemistry being positive for HSV-1 (Figure C). After biopsy results, he was also started on IV acyclovir in addition to fluconazole with improvement in his symptoms. Treatment was extended to 21 days because of the severity of infection. Discussion: Esophagitis is most often caused by non-infectious conditions such as GERD, pill-induced or eosinophilic whereas infectious esophagitis occurs predominantly in patients with imparied immunity. However, it has also been described in otherwise healthy patients. The most common causes of infectious esophagitis are Candida, followed by HSV and CMV. Concomitant infection with 2 organisms is very rare as compared to infection with a single organism. A prospective study in HIV patients showed, 20% of patients had candida with CMV and only 1.8% had HSV with candida [1]. Diagnosis is usually established with an upper endoscopy with biopsies and histopathology. It is also the best way to determine the appropriate antimicrobial therapy. In severe cases of infection with 2 organisms; therapy against both organisms is recommended.[2317] Figure 1. (A, Endoscopic evaluation) (B, PAS stain showing infiltrating hyphae and yeast ) (C, H&E section showing numerous viral inclusions with margination, multinucleosis and moulding).Introduction: Achalasia is a motility disorder of the esophagus characterized by impaired relaxation of the lower esophageal sphincter and loss of peristalsis in the distal esophagus. It is a rare condition with an annual incidence of 0.5-1.2 per 100,000 individuals. The etiology of primary achalasia is unknown, however secondary achalasia can be attributed to malignancy, infections or systemic diseases such as amyloidosis. An infrequent complication of achalasia is esophageal squamous cell carcinoma which has a preva...
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
customersupport@researchsolutions.com
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.