Case report of an unusual hepatic abscess caused by Actinomyces odontolyticus in a patient with human immunodeficiency virus infection

Background Actinomyces odontolyticus is not commonly recognized as a causative microbe of liver abscess. The detection and identification of A. odontolyticus in laboratories and its recognition as a pathogen in clinical settings can be challenging. However, in the past decades, knowledge on the clinical relevance of A. odontolyticus is gradually increasing. A. odontolyticus is the dominant oropharyngeal flora observed during infancy [Li et al. in Biomed Res Int 2018:3820215, 2018]. Herein we report a case of severe infection caused by A. odontolyticus in an immunocompromised patient with disruption of the gastrointestinal (GI) mucosa. Case presentation We present a unique case of a patient with human immunodeficiency virus infection who was admitted due to liver abscess and was subsequently diagnosed as having coinfection of A. odontolyticus, Streptococcus constellatus, and Candida albicans during the hospital course. The empirical antibiotics metronidazole and ceftriaxone were replaced with the intravenous administration of fluconazole and ampicillin. However, the patient’s condition deteriorated, and he died 3 weeks later. Conclusion This report is one of the first to highlight GI tract perforation and its clinical relevance with A. odontolyticus infection. A. odontolyticus infection should be diagnosed early in high-risk patients, and increased attention should be paid to commensal flora infection in immunocompromised individuals.

IL-6 blockade for prophylaxis and management of immune-related adverse events (irAEs) with anti-PD-1 based immunotherapy.

9553 Background: Immune checkpoint inhibitors (ICIs) have activity across many tumor types, but activation of the immune system may also lead to significant, often steroid-refractory irAEs. We sought to determine the activity of tocilizumab, an anti-IL6R monoclonal antibody (mAb), in treatment or prevention of auto-immune irAE in ICI-treated patients (pts). Methods: Institutional databases from 2 melanoma centers were reviewed for pts treated with ICIs and tocilizumab. Treatment and melanoma outcomes were prospectively assessed. Longitudinal assessment of c-reactive protein (CRP) and assessment of clinical improvement (defined as irAE resolution to grade ≤1 CTCAEv5) or prophylaxis (absence of flare, defined as ≥ grade 2) were utilized to evaluate the benefit of tocilizumab. Paired Wilcoxon rank test was used to compare CRP levels prior to ICI administration, at the onset of irAEs and after tocilizumab administration. Results: 22 pts were identified. 2 pts were treated prophylactically (pre-existing dermatomyositis [n = 1] and giant cell arteritis [GCA, n = 1]) before the administration of PD1. 20 pts were treated for management of irAEs due to PD1 +/-CTLA4 (multiple concurrent irAEs [n = 3], steroid refractory irAES [hepatitis & pancreatitis, n = 2], steroid+anti-TNFα refractory colitis [n = 2], steroid+other immunosuppressive-refractory hepatitis [n = 1], cytokine release syndrome-related AEs [n = 6], musculoskeletal irAEs [n = 6]). 15 (68.2%) pts with irAEs required hospitalization and of those, 13 (86.7%) received tocilizumab whilst inpatient. Median time to irAE onset from ICI start was 48 days (range 8-786) and from irAE onset to tocilizumab administration 32 days (range 1-192). Median time to irAE resolution from tocilizumab administration was 7 days (range 1-799). Clinical improvement/benefit was demonstrated in 21/22 patients; one patient with ir-hepatitis did not respond. Median CRP prior to ICI administration was 32mg/L (range 0.3-99), at the onset of irAE 49.5mg/L (range 0.3-251, p = 0.055) and after the tocilizumab administration 18mg/L (range 0.3-18, p = 0.0015). Tocilizumab was well tolerated with self-limiting and transient toxicities in 17 (77.3%) patients. There were two grade 4 events; gastrointestinal tract perforation and Fournier gangrene, the latter unrelated to tocilizumab. Two (9%) patients died due to melanoma. From start of ICI, median progression-free survival (PFS) was 5.88 months and median overall survival (OS) was not reached. Conclusions: Tocilizumab was a well-tolerated and effective steroid-sparing treatment for both management of irAEs, as well as prevention of a flare of pre-existing auto-immune disorders during ICI administration. Prospective trials to evaluate its efficacy and impact on cancer outcomes compared with standard strategies are required.

Clinical case of multiple intestinal perforations caused by magnets

Gastrointestinal foreign bodies in children are a common reason for emergency surgical care. Among the foreign bodies of the digestive tract, special attention should be paid to neodymium magnets, known for their strong magnetic abilities and high resistance to demagnetization. The usual age of hospitalized children with intestinal magnetic bodies is 2–4 years. Swallowing neodymium balls can be accompanied with perforation, fistula, intestinal obstruction, peritonitis, shot bowel syndrome; septic condition with fatalities. The article presents a clinical case of swallowing 17 magnets by two-years-old boy for a long time. The child was hospitalized without anamnestic date of foreign bodies to the digestive tract. Intestinal magnets were diagnosed radiological. Early surgery with gentle tactics was used. The child recovered. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of these Institutes. The informed consent of the patient was obtained for conducting the studies. The authors declare no conflicts of interests. Key words: foreign bodies of digestive tract, perforation, magnets.

Cessation of methotrexate and a small intestinal resection provide a good clinical course for a patient with a jejunum perforation induced by a methotrexate-associated lymphoproliferative disorder: a case report

Background Methotrexate (MTX) is a frequently used drug in the treatment of rheumatoid arthritis (RA), but occurrences of lymphoproliferative disorders (LPD) have been reported in patients undergoing an MTX regimen. Almost half of the patients with methotrexate-associated lymphoproliferative disorders (MTX-LPD) have extranodal lesions; moreover, although extremely rare, digestive tract perforations resulting from the extranodal lesions of MTX-LPD have also been reported. Case presentation We describe the case of an 81-year-old woman with RA who had been prescribed MTX at 6 mg per week for the past 11 years. She was admitted to our hospital with occasional abdominal pain and was first diagnosed with enteritis. Her abdominal pain did not improve, and a computed tomography scan showed abdominal effusion and free air in the abdominal cavity. She was diagnosed with a digestive tract perforation and underwent emergency surgery. The perforation site was identified in the jejunum, and she underwent small intestinal resection around the perforated region. The pathological findings showed an ulcer in the jejunum and infiltration of large atypical lymphocytes around the perforated region. An immunohistochemical examination revealed the expression of a cluster of differentiation 20 and latent membrane protein 1. Considering the patient’s history of RA treated with MTX, she was diagnosed as having Epstein–Barr virus (EBV)-related MTX-LPD with a histological diagnosis of EBVMCU. MTX was discontinued after the surgery, and her soluble interleukin-2 receptor (sIL-2R) levels had returned to normal 1 year later. She has had a good course for the 2 years since surgery and remains asymptomatic with no recurrence of MTX-LPD, as confirmed by the sIL-2R levels. Conclusion We experienced a rare case of the jejunum perforation induced by MTX-LPD. Since only a few cases have been reported of a patient with small intestinal perforation induced by MTX-LPD, further research is necessary to evaluate the clinicopathological features of MTX-LPD. The patient had disease remission after surgery and by discontinuing MTX treatment; our case did not require chemotherapy. EBV-positive patients, especially those with a pathological presentation of EBVMCU, could have a higher likelihood of remission, which could have been a factor in the present case.

Severe pneumoperitoneum in a newborn without any established cause in a tertiary health institution in a low resource setting: A case report

Pneumoperitoneum is the presence of air within the peritoneal cavity. Pneumoperitoneum is said to occur more in neonates than in infants and most cases are idiopathic. However it may be caused by necrotizing enterocolitis (NEC), gastrointestinal tract perforation, iatrogenic causes such as mechanical ventilation and intrathoracic pathology (pneumothorax, pneumomediastinum). Plain abdominal radiograph has a good diagnostic value in evaluating patients with suspected pneumoperitoneum. Pneumoperitoneum can also be diagnosed using computed tomography (CT). A case of neonatal pneumoperitoneum without any established cause is reported due to its rarity. The approach to its management and radiological signs of pneumoperitoneum are also presented.