INTRODUCTION: Strongyloidiasis is a soil-transmitted parasitic infection caused by an intestinal nematode classified as a neglected tropical disease by the World Health Organization. Although predominantly asymptomatic it can potentially turn into a life-threatening disease in immunocompromised host. Epidemiologic studies in the western hemisphere are scarce but even more is the description of the natural course of this disease. The objectives of this study were to identify the different clinical presentations and outcomes associated to Strongyloides stercolaris infection in the Hispanic population in our institution. METHODS: This is a single center, retrospective record review study involving patients diagnosed with S. stercolaris infection via serological studies, stool samples or organ biopsies from 2008 to 2014 RESULTS: A total of 270 patients tested positive during the study period of which 210 (77.8%) were asymptomatic. Out of the patients who presented with symptoms, 25 had pulmonary manifestations, 21 gastrointestinal, 5 rash, 9 with more than one manifestation of which 5 presented with hyperinfection. The most common laboratory abnormalities were an elevated eosinophil count: 1.4 × 103/ul (normal: 0-0.1 × 103/ul) and eosinophil percent: 15.5% (normal: 0-7%). The other laboratory parameters were essentially unaffected. The mean age at diagnosis was 75.4 years old. The most common reasons for testing for S. stercoraliswere eosinophilia (n = 235), asthma (n = 21), diarrhea (n = 20), rash (n = 10) and others (n = 31). CONCLUSION: Evolving globalization trends have increased migratory rates around the globe. People from endemic countries can easily travel to places where S. stercoralis is not endemic. Natural disasters account for increased translocation of people from endemic to non-endemic areas. More recently, Hurricane María struck Puerto Rico and the Caribbean during September 2017. In its aftermath, nearly 400,000 Puerto Ricans left the island and established themselves in the continental United States, a crisis documented in multiple newspaper articles, columns and news outlets. The present study highlights the need to establish guidelines aimed towards increased screening of patients in communities with known increased migrant flow from endemic countries in order to timely diagnose and prevent the potentially fatal outcomes that may occur as a result of steroid or immunosuppressive therapy in patients with untreated strongyloidiasis.
INTRODUCTION: Neuroendocrine tumors (NETs) of the ampulla of Vater represent less than 0.3% of gastrointestinal NETs and less than 2% of all periampullary malignancies. There are approximately 139 cases in literature, making this rare condition a diagnostic challenge. Jaundice is the predominant symptom followed by abdominal pain. Acute pancreatitis as the initial presentation has seldom been reported. Herein we report a case of a patient who presented with acute pancreatitis and biliary obstruction secondary to an ampullary NET. CASE DESCRIPTION/METHODS: Case of a 74-year-old male with hypertension who reported burning epigastric pain. Denied fever, vomits, weight loss, diarrhea, flushing or dyspnea. Physical examination with epigastric tenderness. Laboratories showed elevated alkaline phosphatase 398 U/L, total bilirubin 3.4 mg/L, lipase 594 U/L and amylase 216 U/L. Contrast abdominopelvic CT showed a duodenal periampullary mass with common bile duct measuring 1.1 cm and intrahepatic and extrahepatic dilatation. Endoscopic retrograde cholangiopancreatography (ERCP) revealed an irregular, ulcerated ampullary mass. Biopsy showed poorly differentiated carcinoma. Immunostains were positive for chromogranin, synaptophysin, CK7, weakly positive for CDX-2. Negative for TTF-1 and CK20. Octreotide scintigraphy with no uptake. Somatostatin, chromogranin, and 5-hydroxy-in-dole acetic acid were normal. Patient underwent surgical treatment with pancreaticoduodenectomy. DISCUSSION: The rarity of ampullary NETs and its proliferation under an intact mucosa makes it difficult to detect in biopsy. Most of the time the diagnosis is based on histology and preoperative diagnosis may be challenging since they clinically present like adenocarcinoma. The usual presentation of jaundice and abdominal pain places this diagnosis low on the differential. In our case, the unusual morphologic appearance likely facilitated obtaining an assertive pre-operative diagnosis. Our patient presented with obstructive jaundice and acute pancreatitis, which occurs in less than 6% of cases. The clinical picture of ampullary NETs is easily confounded given the associated symptoms and biopsy challenges. A high index of suspicion is paramount to ensure this rare diagnosed is not missed. Pancreaticoduodenectomy has been advocated as the treatment of choice regardless of size due to high risk of occult nodal metastases. Considering this diagnosis within the differential is important given the drastically different outcomes for patients if caught early.
INTRODUCTION: Transarterial chemoembolization (TACE) is often performed for hepatocellular carcinoma. Side effects can occur due to arterial ischemia and cytotoxicity from chemotherapy delivery. TACE can be complicated via inadvertent embolization of arteries supplying the liver, gallbladder, stomach and pancreas. The association of acute pancreatitis with TACE is rare. The proposed mechanism involves regurgitation of embolic beads from the hepatic artery into the arterial supply of the pancreas. Acute pancreatitis can develop up to 15 days after TACE. Herein we present a case of groove pancreatitis occurring after TACE. Groove pancreatitis is a rare variant of focal chronic pancreatitis affecting the area between the head of the pancreas, duodenum, and the common bile duct. Functional and anatomical obstruction of the minor papilla from viscous pancreatic secretions leads to impaired pancreatic enzyme outflow and proliferation of Brunner's glands causing pancreatitis. Imaging may show a submucosal mass which may confound the diagnosis since pathologies including leiomyoma, gastrointestinal stromal tumor and ampullary carcinoma may have similar imaging findings. Groove pancreatitis remains largely unfamiliar to most physicians thus making its true incidence a challenge. CASE DESCRIPTION/METHODS: This is the case of a 69-year-old male patient with multicentric hepatoma secondary to chronic Hepatitis C, status-post TACE who presented to ER with a nine-day history of epigastric abdominal pain and nausea. The patient had received TACE nine days prior and was admitted with the diagnostic impression of acute pancreatitis. The physical exam was remarkable for flank pain, negative murphy's sign. Labs showed stable hemoglobin and platelet levels. Liver chemistry showed a mixed pattern with AST minimally elevated and ALT at 102, Alk Phos at 225, Amylase slightly elevated at 135 and lipase elevated at 161. Imaging studies showed acute pancreatitis with possible necrotic collection of 2.1 cm at the pancreatic head and uncinate process, duodenitis, mild gallbladder wall thickening and no ductal dilation. Likely etiology was pancreatitis secondary to recent TACE. DISCUSSION: Pancreatitis is a rare complication of TACE. Although elevated pancreatic enzymes may be seen in up to 40% of TACE cases, the incidence of symptomatic pancreatitis after TACE is low at 2%-4%. Despite this low incidence, it is a complication that one should be aware of in patients undergoing TACE procedure given its high morbidity and mortality.
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