Introduction: Acute esophageal necrosis, or black esophagus, is a rare clinical entity manifesting as upper gastrointestinal bleeding and complicating various conditions. However, black esophagus in the setting of diabetic ketoacidosis (DKA) has been rarely reported. We present a case of a 36-year-old male with black esophagus presenting as hematemesis complicating an episode of DKA. Case Description/Methods: A 36-year-old male with uncontrolled type 1 diabetes mellitus complicated by end-stage renal disease and hypertension presented to the emergency department with abdominal pain, nausea, and vomiting. Patient reported worsening abdominal pain and associated blood-tinged emesis. On presentation, patient was hemodynamically stable. Physical exam included an abdomen that was diffusely tender to palpation without peritoneal signs. Initial labs remarkable for serum glucose 1491, anion gap 41, bicarbonate 9, and hemoglobin 7.5. Patient was admitted to Critical Care for insulin drip and intravenous fluid resuscitation for DKA. Later, patient had an episode of hematemesis resulting in tachycardia, hypotension, and drop in hemoglobin to 5.6. Patient was further resuscitated with blood transfusions with improvement in hemodynamics and hemoglobin to 8.9. Continuous pantoprazole infusion was initiated. Upper endoscopy demonstrated severe, ulcerative necrotizing circumferential esophagitis in the middle and lower third esophagus and a medium size blood clot without evidence of active bleeding. No biopsies were taken due to concern for possible false lumen; CT chest with contrast demonstrated no signs of esophageal perforation. Following EGD, patient had several small self-limiting episodes of hematemesis and melena, while maintaining hemodynamics. He was continued on pantoprazole infusion and placed on strict nothing by mouth (NPO) precautions for 3 days with gradual advancement of diet. He received 6 days of empiric antimicrobial therapy with ampicillin-sulbactam and fluconazole. Patient reported no further episodes of hematemesis. Hemoglobin stabilized around 8.0 (Figure). Discussion: DKA is a rare but life-threatening cause of acute esophageal necrosis which may develop due to a combination of tissue hypoperfusion, impaired mucosal defenses, and gastric reflux. Upper gastrointestinal bleeding in the setting of DKA should raise suspicion for black esophagus which is a potential cause of mortality. Early diagnosis and treatment of underlying etiology are the key factors in management.
BackgroundPatients with chronic inflammatory arthritis (CIA) are at increased risk for the development and mortality from COVID-191. Vaccinations are integral to the management of these conditions. Disease-modifying antirheumatic drugs (DMARDs) used to treat CIA have the potential to blunt the immune response and efficacy of vaccinations2. There is little data on the effect of DMARDS used for CIA on the response to novel mRNA vaccines, limiting guidelines to direct therapy.ObjectivesAssess the antibody response (ABR) to the SARS-CoV-2 mRNA vaccines in patients with CIA on treatment with either methotrexate (MTX), tumor necrosis factor inhibitors (TNFi), or both with healthy controls. Determine the effect of interrupting therapy after vaccination in patients with CIA on the ABR to the vaccine.Methods63 patients with rheumatoid or psoriatic arthritis on MTX, TNFi or both were recruited from a community-based rheumatology practice. All subjects received two doses of a mRNA COVID vaccine. Use of hydroxychloroquine (HCQ), NSAID’s, and prednisone (Pred) ≤10mg daily were allowed. Those with prior COVID infection were excluded, as determined by SARS-CoV-2 nucleocapsid assay. 26 healthy age-matched controls were obtained from banked blood from Labcorp. IRB approval was obtained, and patients were consented to participate in the study. SARS anti-receptor binding domain IgG antibodies were measured by electro chemiluminescent immunoassay 90-120 days post initial vaccine dose. Patients were divided into 3 groups based on therapy:1. MTX monotherapy2. TNFi with eternacept (ETN) or adalimumab (ADA)3. A combination of MTX with either ETN or ADAEach of the groups were subdivided into two categories:1. Continued treatment uninterrupted at the time of each of the two vaccines.2. Held treatment for two weeks after each vaccine. Statistical significance (p<.005) determined using one way ANOVA with Scheffe procedure and Student’s T-test.ResultsThe 63 patients with CIA had a significantly lower ABR to vaccine compared with healthy controls (p=0.001). Further analysis was limited by sample size: The MTX held group had a higher ABR than the MTX continued group (mean IgG=35.5 vs 21.74; p=0.14), demonstrating a trend toward increased immunogenicity. There was a similar ABR to vaccine between those on TNFi who held vs continued therapy (mean IgG 20.83 vs 28.65; p=0.525). Combination MTX +TNFi held vs continued groups demonstrated a trend toward increased immunogenicity when holding therapy post vaccine (mean IgG 42.4 vs 22.7; p=0.44). All treatment groups were comparable in Pred, HCQ, NSAID use, age, Rapid 3 score, and time between vaccination and blood draw for antibody levels (VI).Table 1.Antibody response to VaccinationVariableMTXTNFMTX + TNFiControlsp valueTestMSDMSDMSDMSDIgG28.9530.0123.9614.7735.2738.8166.3138.060.001ANOVADrugVariableHeldContinuedp valuenMSDnMSDMTXAge2267.957.332071.311.070.251T-testIgG2235.529.922021.7429.130.14VI2297.2713.712098.1510.190.817TNFiAge664.510.19470.2513.770.467IgG620.8310.07428.6520.90.525VI698.6722.24493.7512.290.701MTX + TNFiAge763.866.36462.7511.530.839IgG742.4345.11422.7524.920.448VI710019.09497.7522.590.864VariableCIAControlsp valuenMSDnMSDAge6363.059.612652.318.840.001T-testVI6397.7914.312688.655.430.002M: Mean; VI: Vaccine Interval in daysConclusionThe ABR in patients with CIA to the mRNA vaccine appeared to be blunted by ongoing therapy with MTX. This effect was attenuated by holding MTX post-vaccine. There was no significant difference in the ABR to vaccine in patients on TNFi who held vs continued these agents after vaccine, due to small sample size. Patients with CIA on DMARD therapy had a significantly lower ABR to the vaccine compared to healthy controls. Our findings need further validation in a larger cohort. Clinicians may consider holding MTX for two weeks post vaccination to optimize the immune response to the vaccine.References[1]Sepriano A, et al. Ann Rheum Dis. 2020;79(6):760-770[2]Hua C, et al. Arthritis Care Res 2014;66(7):1016-1026AcknowledgementsWe would like to thank Jamie Reidy and Judy Wolf for their efforts in the Arnot laboratory, Dr. Manav Bandlamudi and Dr. Frank Edwards for their research support.Disclosure of InterestsNone declared
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