Rejected

Tofacitinib is an anti-JAK/STAT small molecule approved for treatment of adults (but not children and adolescents) with moderate to severe ulcerative colitis. Data is limited in children and teens although two major centers have shown efficacy as both mono- and dual – combination therapy using tofacitinib in pediatric patients refractory to anti-TNF agents. We present a 16-year-old female diagnosed with inflammatory ileocolonic Crohn's disease without upper gastrointestinal involvement after presenting with several months of abdominal pain, diarrhea, and unintentional weight loss. Laboratory evaluation was notable for normal inflammatory markers, albumin and complete blood count and an elevated stool lactoferrin. Initial endoscopic evaluation revealed moderate to severe pancolitis and patchy ileitis; biopsies noted mild chronic active ileitis and moderate to severe chronic active pancolitis without dysplastic or atypical changes. She was started on infliximab for induction and maintenance therapy and dosage was increased due to suboptimal levels and marginal symptomatic improvement. However, despite increased dosing plus a course of budesonide (Uceris), she had minimal improvement in her symptoms and ongoing elevation of her lactoferrin. Given an equivocal result on a Clostridium difficile testing (GDH antigen positive only), she was started on oral vancomycin which resulted in mild improvement, but not resolution, of diarrhea and abdominal pain. This was continued after completion of a 14-day course (and subsequent negative testing) due to increased stool frequency with discontinuation of the medication and improvement with reinitiating it. She had severe pancolitis (Mayo 2 – 3) but normal TI on repeat colonoscopy 5 months after diagnosis. Biopsies (reviewed by a panel of adult GI pathologists) were notable for reactive atypia with features concerning for early dysplasia in the ascending and descending colon. Due to disease severity and rapid progression plus histologic changes concerning for possible dysplasia despite optimized therapy with infliximab and repeat negative C. difficile testing, she was started on tofacitinib 10 mg twice daily along with oral vancomycin. She had complete resolution of diarrhea, abdominal pain, and early satiety within a week; repeat fecal lactoferrin was negative (<30). She underwent repeat colonoscopy with chromoendoscopy 5 months after initiation of tofacitinib which revealed mild acute ileitis but no active colonic inflammation, atypia or dysplasia. This is the first report to our knowledge that an adolescent patient with colonic predominant Crohn's disease has complete resolution of atypia and possible early dysplasia with tofacitinib therapy.

Background Voiding cystourethrography (VCUG) is used to diagnose vesicoureteral reflux (VUR); however, it is an invasive procedure and can be psychologically distressing. Procedural sedation is occasionally utilized to alleviate anxiety during VCUG, and some patient populations may get referred more readily for sedation than others. Sedative medications may also impact the results of the test due to their effects on smooth muscle. The goals of this study were to compare patient characteristics between those that were referred for procedural sedation and those that were not and to compare VCUG results between sedated and non-sedated patients. Methodology We performed a retrospective cohort study of patients aged 2-18 years undergoing VCUG during a five-year period. Sedated patients were matched with non-sedated patients controlling for referring provider and procedure year. Exclusion criteria included chronic catheterization, same-day surgery, current intensive care admission, and sedation restrictions. A total of 284 patients were included. Demographic information, medical comorbidities, and VCUG results were analyzed. Results There were no significant differences between sedated and non-sedated patients in any demographic variables. Neurologic, developmental, and gastrointestinal comorbidities were more common in sedated patients. On multivariate analysis, having more than one comorbid condition was the only significant predictor of referral for procedural sedation. There were no significant differences in VCUG results between sedated and non-sedated patients. Conclusions Patients with comorbidities were more likely to receive procedural sedation for VCUG. Procedural sedation did not have a significant impact on test results, suggesting its potential utility in relieving pain and anxiety associated with VCUG.

Multiple endocrine neoplasia type 1 (MEN1) is a rare autosomal dominant disorder characterized by tumors of parathyroid, anterior pituitary, and pancreatic islet cells. Pituitary adenomas in MEN1 can be aggressive and invade surrounding structures including the skull base. However, acute bacterial meningitis in patients with newly diagnosed macroprolactinomas is an exceptional finding. We present the case of a young man with suppurative meningitis complicating an invasive macroprolactinoma as the initial manifestation of MEN1. A 33-year-old male was admitted to the hospital with fever, headache, and nuchal rigidity and subsequently diagnosed with bacterial meningitis. Computed tomography (CT) and subsequent magnetic resonance imaging (MRI) of the sella turcica revealed a 5 x 3.5 cm pituitary mass invading both cavernous sinuses and the left sphenoid sinus. Laboratory evaluation was notable for significantly elevated serum prolactin level (2,484 ng/mL, 2.6-13.2) and evidence of hypopituitarism. Primary hyperparathyroidism was indicated by hypercalcemia (13.5 mg/dL, 8.5-10.5), low serum phosphorus (2.0 mg/dL, 2.5-4.9), and elevated intact parathyroid hormone (PTH) level (290 pg/mL, 15-60). No visual field deficits were identified. The patient was managed with hydrocortisone, levothyroxine, and cabergoline. However, cerebral spinal fluid (CSF) rhinorrhea compelled subtotal transsphenoidal resection of the tumor and repair of the CSF leak. Three-and-a-half gland parathyroid resection was performed after recovery from pituitary surgery and successfully treated hypercalcemia. Abdominal MRI revealed a 1.2 cm cystic mass in the neck of the pancreas, and pancreatic polypeptide was approximately fourfold elevated. A clinical diagnosis of MEN1 was made based on the occurrence of macroprolactinoma, multiple parathyroid adenomas, and pancreatic findings. This case appears to be the first in which bacterial meningitis was the initial presentation of an invasive macroprolactinoma in a patient with MEN1.

In this retrospective study we examined the safety and efficacy of high-dose intravenous immunoglobulin (HD-IVIG) therapy in preventing BKVN in pediatric renal transplant recipients with BK-viremia/viruria.

Maggot debridement therapy (MDT) has seen a resurgence in recent years in the treatment of hard-to-heal wounds, as a result of rising antibiotic resistance. The sterilised larvae of have been used in MDT in Malaysia since 2003, with encouraging results for the treatment of hard-to-heal diabetic wounds. We report a case series of 30 patients selected from our clinic by convenient sampling with diabetic lower limb ulcers treated with MDT. The average age of patients receiving MDT was >50 years. Of the 30 patients in the study, nine were female and 21 were male. All patients had underlying diabetes, two patients had leg ulcers and 28 patients had diabetic foot ulcers. Sterilised larvae were applied via a standard method of 10 maggots per square centimetre and dressed with sterile gauze. The study endpoint was defined as ≤5% coverage with slough or necrotic tissue following three successive applications of MDT. In this study, maximum debridement of wounds was achieved in 96.6% (29 patients) of our patients, with ≤5% coverage with slough or necrotic tissue, in addition to a reduction in wound-related pain, as assessed by a visual analogue scale. No adverse events were reported. The findings of this study support the use of MDT as a safe, efficacious, and cost-effective method of managing diabetic wounds.

During the SARS-CoV-2 pandemic, various rashes associated with COVID-19 infection have been reported, including urticaria. Urticaria is a limited and usually benign condition, presenting as pruritic wheals, with or without edema. A 39-year-old woman presented with a pruritic rash on her arms spreading to her trunk and face over two days, followed by headache, nausea, vomiting, abdominal discomfort, diarrhea, myalgia, arthralgia, anosmia, and dyspepsia for three days. Fever, dry cough, and odynophagia started on the day of the consult. The patient had a history of hypertension but denied a history of atopic conditions, similar previous presentations, or recent ingestion of new medications. SARS-CoV-2 COVID-19 PCR testing was positive. She was prescribed oral antihistamine for the itching and was discharged. During a follow-up after two weeks, the patient was asymptomatic with complete resolution of the rash on day 7 of symptoms. Knowing the cutaneous manifestations of COVID-19 can aid in the early identification of this disease and prevent misdiagnosis. The presence of cutaneous manifestations in COVID-19 is suggested to be related to disease severity, but data are needed to study any prognostic value of dermatologic manifestations in COVID-19.

Common scabies can be difficult to diagnose and treat. There are limited data on the clinical characteristics of patients who may benefit from combined topical permethrin plus oral ivermectin. Postscabetic itch is common, but there is scant data describing its prognosis and management.

Crohn's disease (CD) and ulcerative colitis (UC) are the two most prevalent forms of inflammatory bowel disease (IBD) causing frequent diarrhea, rectal bleeding, fatigue, and abdominal pain. IBD may result in complications requiring hospitalizations and surgical procedure, hence IBD can negatively impact patients' quality of life, work productivity, and increase societal economic burden. Limited data exists assessing epidemiologic trends and population-level health outcomes among patients with IBD in Sweden. This study assessed the trends in annual incidence and prevalence of CD, annual inpatient and outpatient visits, employment status and sickness absence among adults with IBD in Sweden from 2001 to 2017.

Urinary tract infections are very prevalent among women. The majority of urinary tract infections are uncomplicated and can be managed empirically with no further investigations. However, imaging studies may be indicated in patients with severe or persistent symptoms. Complicated urinary tract infections typically develop in the setting of diabetes mellitus. We report a case of a 52-year-old woman who presented to the emergency department with severe lower abdominal pain for two days that was associated with nausea, vomiting, and fever. There was no history of change in urine or bowel habits. Besides the history of well-controlled asthma, the patient was not known to have any comorbid medical condition. Upon examination, the patient had tachycardia, low-grade fever, and a localized suprapubic tenderness with guarding. Laboratory investigation revealed leukocytosis, elevated erythrocyte sedimentation rate and C-reactive protein, and deranged renal functions. Further, urinalysis revealed numerous white blood cells, red blood cells, positive nitrite, and leukocyte esterase. A computed tomography scan demonstrated the presence of small locules of gas within the lumen and the wall of the bladder representing emphysematous cystitis. The patient was admitted to the intensive care unit. She received aggressive hydration therapy and a short course of opioid therapy for pain control. Broad-spectrum antibiotic therapy in the form of piperacillin-tazobactam was initiated. Over the following few days, the patient exhibited significant improvement in his symptoms and resolution of the laboratory parameters. Emphysematous cystitis is a rare infection of the lower urinary tract with gas formation. The case highlighted that such a condition may develop in the absence of diabetes mellitus or other risk factors. Prompt treatment is crucial as emphysematous cystitis can be life-threatening if the diagnosis is missed or delayed.

Dysphagia lusoria is a congenital abnormality characterized by an aberrant right subclavian artery. It often presents as either an incidental finding on imaging or chronic dysphagia. We describe the case of a 66-year-old female who presented with severe chest pain, worse with swallowing, along with an ongoing globus sensation. She was found to have a negative cardiac workup for ischemia with a subsequent computed tomography angiogram (CTA) of the chest showing an abnormal right subclavian artery. We emphasize the unique diagnostic approach of this rare anatomical anomaly and its potential presentation that worsens with deglutition.