A203 PAVING THE WAY TO THE DUODENUM: A CASE REPORT OF DUODENAL TUBERCULOSIS

Background

Duodenal tuberculosis (DTB) is an uncommon manifestation of tuberculosis (TB), representing only 0.5% of all TB cases. The nonspecific features of its clinical presentation make diagnosis challenging, which can lead to delayed identification and even inappropriate treatments. Further, the location is also difficult to reach on conventional endoscopy and there are few studies on the use of balloon enteroscopy to diagnose DTB.

Aims

We report a case of DTB diagnosed using balloon enteroscopy that was successfully treated with symptom resolution. We also highlight uncommon features of DTB, including cobblestoning seen on endoscopy and villous blunting with duodenal lymphocytosis seen on histopathology.

Methods

Case report

Results

A 30-year-old previously healthy male returning from India 16 months prior presented to the emergency department with 1 month of abdominal distension, non-bloody diarrhea, and night-sweats. Examination was notable for fever and a distended abdomen. Computed-tomography showed thickening of the jejunum and ileum, with omental fat-stranding and intra-abdominal lymphadenopathy. As the lesion appeared out of reach for conventional endoscopy, balloon enteroscopy was performed, revealing an area of cobblestoning in the duodenum. Acid-fast bacilli (AFB) staining was negative. While TB culture was pending, a second balloon enteroscopy was performed, with AFB staining negative on repeat biopsy. Pathology showed villous blunting and increased intraepithelial lymphocytes but was negative for granulomas. As the diagnosis remained uncertain, endoscopic ultrasound-guided lymph node biopsy was performed and multiple lymph nodes were seen in the gastro-hepatic area. Lymph node biopsy AFB staining was also negative. 4 weeks later, pathology from the first balloon enteroscopy returned positive for TB. The remaining biopsy cultures were negative for TB. The patient was treated with standard of care treatment. At 2 and 4 months of follow-up, he reported complete resolution of symptoms.

Conclusions

The diagnosis of DTB is challenging due its non-specific presentation and rarity. Our case highlights the difficulty of diagnosis as endoscopic findings such as cobblestoning are highly uncommon. We provide support for the use of balloon enteroscopy as a novel method for diagnosis of DTB. With early identification, we were able to provide appropriate therapy and prevent propagation of the disease.

Funding Agencies

None

Diagnosing Portal Hypertension with Noninvasive Subharmonic Pressure Estimates from a US Contrast Agent

Background The current standard for assessing the severity of portal hypertension is the invasive acquisition of hepatic venous pressure gradient (HVPG). A noninvasive US-based technique called subharmonic-aided pressure estimation (SHAPE) could reduce risk and enable routine acquisition of these pressure estimates. Purpose To compare quantitative SHAPE to HVPG measurements to diagnose portal hypertension in participants undergoing a transjugular liver biopsy. Materials and Methods This was a prospective cross-sectional trial conducted at two hospitals between April 2015 and March 2019 (ClinicalTrials.gov identifier, NCT02489045). This trial enrolled participants who were scheduled for transjugular liver biopsy. After standard-of-care transjugular liver biopsy and HVPG pressure measurements, participants received an infusion of a US contrast agent and saline. During infusion, SHAPE data were collected from a portal vein and a hepatic vein, and the difference was compared with HVPG measurements. Correlations between data sets were determined by using the Pearson correlation coefficient, and statistical significance between groups was determined by using the Student t test. Receiver operating characteristic analysis was performed to determine the sensitivity and specificity of SHAPE. Results A total of 125 participants (mean age ± standard deviation, 59 years ± 12; 80 men) with complete data were included. Participants at increased risk for variceal hemorrhage (HVPG ≥12 mm Hg) had a higher mean SHAPE gradient compared with participants with lower HVPGs (0.79 dB ± 2.53 vs -4.95 dB ± 3.44; P < .001), which is equivalent to a sensitivity of 90% (13 of 14; 95% CI: 88, 94) and a specificity of 80% (79 of 99; 95% CI: 76, 84). The SHAPE gradient between the portal and hepatic veins was in good overall agreement with the HVPG measurements (r = 0.68). Conclusion Subharmonic-aided pressure estimation is an accurate noninvasive technique for detecting clinically significant portal hypertension. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Kiessling in this issue.

Brainstem auditory evoked responses in foals: reference values, effect of age, rate of acoustic stimulation, and neurologic deficits

Background

Age and rate of acoustic stimulation affect peak latencies in brainstem auditory evoked responses (BAER) in humans. Those effects are unknown in foals.

Hypothesis/Objectives

Our goals were to (1) establish reference values for BAER in foals by using 3 different stimulation protocols, (2) evaluate the effects of age and stimulation frequencies on BAER tracing in foals up to 6 months old, and (3) compare the data with BAER obtained from foals with central nervous system (CNS) disorders.

Animals

Thirty‐nine neurologically normal foals and 16 foals with neurologic diseases.

Methods

Prospective observational clinical study. BAER recorded by using 3 protocols of stimulation (11.33 repetitions per second [Hz]/70 decibel normal hearing level [dBNHL]; 11.33 Hz/90 dBNHL; 90 Hz/70 dBNHL).

Results

No effect of age was observed in normal foals (P > .005). No significant difference was observed for latencies and interpeak latencies (IPL) when comparing foals with neurologic diseases and normal foals (P > .05), but 78.6% of foals with neurologic diseases had an asymmetry in their tracing, reflecting a difference in conduction time between the left and right side of the brainstem. Increasing the stimulation rate did not improve detection of CNS disorders.

Conclusions and Clinical Importance

We propose BAER reference values for foals up to 6 months of age by using 3 protocols. Most foals with neurologic deficits had abnormal BAER tracing.

Impact of a preventive programme on the occurrence of incidents during the transport of critically ill patients

OBJECTIVE

Incidents related to transport of critically ill patients have been extensively reported. The objective of this study was to determine the effect of an interdisciplinary preventive programme used by all intensive care unit team members involved in patients' transport on the rate of these incidents.

METHODS

A clinical quality improvement audit using a prospective pre and post intervention design was performed among medical and surgical patients hospitalised in intensive care who required intra or inter-hospital transport.

RESULTS

A total of 180 transports occurred in the pre-implementation phase of the study and 187 transports in the post-implementation phase. A 20% absolute reduction of incidents was observed (57.2% vs. 37.4%, p<0.001). Statistically significant reductions were obtained for the technical problems category of incidents (25% vs. 7.5%, p<0.001) as well as the problems related to patient's mobilisation category (14.4% vs. 7.5%, p=0.05). Clinically significant trends were also observed for the clinical deterioration (24.4% vs. 17.1%, p=0.11) and undesired delay before test (23.9% vs. 17.6%, p=0.14) categories but did not reach statistical significance.

CONCLUSIONS

A preventive programme applied by all care providers involved in transport of critically ill patients was associated with a reduction of incidents. The application of such a programme should be acknowledged as a standard of care considering the risks inherent to the transportation of ICU patients.

Evaluation of the contribution of cyclooxygenase 1 and cyclooxygenase 2 to the production of PGE2 and PGF2 alpha in epithelial cells from bovine endometrium

In ruminants, the production of prostaglandins by the endometrium is critical for recognition of pregnancy. In the absence of an embryonic signal, luteolytic pulses of PGF(2 alpha) are released by the uterus. In contrast, the presence of a viable conceptus reduces the production of PGF(2 alpha) relative to PGE(2) and prevents luteolysis through the release of trophoblastic interferon (IFN-tau). Initially, it was thought that epithelial and stromal endometrial cells were specialized in the production of a single type of prostaglandin. However, purified cell populations of both types of cell can produce PGF(2 alpha) and PGE(2); therefore, selective production of PGF(2 alpha) and PGE(2) must be regulated within each type of cell. Two distinct prostaglandin synthases, cyclooxygenase 1 and cyclooxygenase 2, are involved in prostaglandin production and each may catalyse the production of a different prostaglandin. This possibility was investigated in cultured epithelial cells from bovine endometrium. Cells were treated with oxytocin or arachidonic acid, and expression of cyclooxygenase 1 and cyclooxygenase 2 proteins was monitored over time and correlated with prostaglandin accumulation. Cells were also treated with increasing doses of inhibitors of cyclooxygenase 1 or cyclooxygenase 2 (non-steroidal anti-inflammatory drugs; NSAIDs) with or without arachidonic acid or oxytocin: flurbiprofen (0-50 micromol l(-1)) was used as a non-selective inhibitor; valeryl salicylate (0-500 micromol l(-1)) was used as a cyclooxygenase 1 inhibitor and NS-398 (0-1 micromol l(-1)) was used as a cyclooxygenase 2 inhibitor. After stimulation with arachidonic acid or oxytocin, prostaglandin production and expression of cyclooxygenase 2 protein were increased. All inhibitors were able to block basal and stimulated prostaglandin production. These results indicate that in endometrium most, if not all, prostaglandin production is probably processed through cyclooxygenase 2.

The immunophenotype of blood and cerebrospinal fluid mononuclear cells in dogs

Inflammatory neurologic diseases are common in dogs, but establishing a definitive diagnosis often is difficult. Nucleated cell number and type in cerebrospinal fluid (CSF) rarely are suggestive of an etiologic agent. We speculated that CSF leukocyte immunophenotyping would be a useful adjunct in the investigation of canine inflammatory neurologic diseases by yielding more specific etiologic information. The goals of this study were to establish the feasibility of flow cytometric evaluation of individual canine CSF samples and to identify the cell distribution in healthy dogs. The mononuclear cell populations of paired blood and CSF samples from 23 healthy dogs were characterized by labeling of cells with antibodies against CD4, CD8alpha, CD21, and CD14 molecules and by flow cytometric analysis of their expression. The mean proportion of CD4+ and CD21+ cells was significantly higher in blood than in the CSF (P < .002 and P < .001, respectively). In contrast, the mean proportion of CD14+ and CD8a+ cells was not significantly different between blood and CSF (P = .5 and p = .9, respectively). These findings demonstrate differences in the distribution and function of mononuclear cells in the circulating venous and subarachnoid compartments in the dog.

Functional MRI as a tool to assess vision in dogs: the optimal anesthetic

Functional magnetic resonance imaging (fMRI) is a recent advance in neuroimaging that provides a picture of brain activity with excellent spatial resolution. Current methods used to evaluate canine vision are poorly standardized and vulnerable to bias. Functional MRI may represent a valuable method of testing vision in dogs if the impacts of anesthesia on fMRI are understood. Six dogs were scanned during visual stimulation, each under three different anesthetic protocols (isoflurane, propofol, fentanyl/midazolam) to address the questions: (1) Can visually evoked fMR signals be reliably recorded in anesthetized dogs? and (2) Which anesthetic agent permits the least suppression of visually induced fMR signal in dogs? This study confirms that visual stimuli reliably elicit neural activity and fMR signal change in anesthetized dogs. No significant differences in images acquired under the three anesthetics were found, and there was no significant relationship between anesthetic dose and brain activity, within the range of doses used in this study. Images obtained during isoflurane anesthesia were more consistent between dogs than those obtained with the other two agents. This reduced variation may reflect the fact that inhalant anesthesia is more easily controlled than intravenous anesthesia under conditions associated with high field fMRI.

Modification of a commercial electrospray nebulizer for operation in a liquid chromatography/mass spectrometry system at flow rates in the low microL/min range

A simple and inexpensive approach to convert the electrospray nebulizer of a commercial liquid chromatography/mass spectrometry (LC/MS) system (HP 1100) to accommodate lower flow rates has been proposed and evaluated. This modification consists of simply replacing the nebulizer needle by a commercially available stainless steel needle with a smaller internal diameter. Experiments were conducted in order to optimize operational parameters. Using two different internal diameter needle sizes, flow rates ranging from 1 to 250 microL/min could be accommodated. The modification presented allows an extension of the range of compatible flow rates without major modification of the standard design of the interface.

Liquid chromatographic-mass spectrometric determination of itraconazole and its major metabolite, hydroxyitraconazole, in dog plasma

A fast, reliable and sensitive liquid chromatography-mass spectrometry (LC-MS) assay for the determination of itraconazole and hydroxyitraconazole in dog plasma has been developed. The analysis involves a simple liquid-liquid extraction followed by LC-MS analysis using electrospray ionization in the positive mode. Total separation of itraconazole, hydroxyitraconazole and the internal standard, miconazole, was achieved on a C18 column in 3.5 min using an isocratic mixture of acetonitrile and 10 mM ammonium acetate. The response was linear over four-orders of magnitude, allowing reliable quantification of each species. This paper describes the development of the method and its validation.

Quantitation and characterization of phospholipids in pharmaceutical formulations by liquid chromatography-mass spectrometry

A simple and fast method for phospholipid analysis was developed using high-performance liquid chromatography-mass spectrometry with an atmospheric pressure ionization interface. Separation of the phospholipid molecular species was achieved using a linear gradient of a mixture of chloroform-10 mM ammonium acetate-methanol (30:5:65) on a silica column. Optimization of the mass spectrometer conditions has allowed the method to separate and detect the phospholipids mainly as protonated molecular species. In comparison to existing LC-MS methods, improvement in the total analysis time and sensitivity were achieved. Separation of all major phospholipid molecular classes was achieved in less than 6 min. Marked improvement was observed in the linearity of the response of the phospholipids studied providing a linear response over three orders of magnitude. Data supporting the validation of this method for the characterization of major phospholipids molecular species are also presented.

Clinical, cerebrospinal fluid, and histological data from thirty-four cats with primary noninflammatory disease of the central nervous system

The purpose of this study was to report the clinical, cerebrospinal fluid (CSF), and histological data derived from a study of 34 cats with noninflammatory central nervous system (CNS) disease, and to report the activities of the enzymes lactate-dehydrogenase (LDH), aspartate transferase (AST), and creatine kinase (CK) in the CSF from 15 cats with a variety of CNS diseases. The cats were part of a study of 61 cats that were admitted to two university clinics because of signs of CNS disease. The most frequent noninflammatory diseases were neoplasia (n = 12) and ischemic encephalopathy (n = 4). The majority of cats with CNS neoplasia had a mild increase in CSF protein concentration (less than 1 g/L [100 mg/dL]), an increased percentage of neutrophils or lymphocytes, and a normal total white cell count. Cats with ischemic encephalopathy (IE) had a mild to moderate increase in CSF protein concentration (< or = 2 g/L [200 mg/dL]) and a mild increase in white cell count (< or = 10 cells/microL) with an increased percentage of lymphocytes. The enzymes LDH, AST, and CK in the CSF were not sensitive indicators of chronic CNS disease. The CSF differential cell count was frequently abnormal when the total white cell count was normal, and blood contamination in the CSF samples was a frequent problem that had to be considered in the interpretation of the results. The history, signalment, and clinical signs, when combined with the CSF findings, were valuable in the diagnosis of noninflammatory CNS disease.

Clinical, cerebrospinal fluid, and histological data from twenty-seven cats with primary inflammatory disease of the central nervous system

The purpose of this report is to present the clinical, cerebrospinal fluid (CSF) and histological data from 27 cats with inflammatory disease of the central nervous system (CNS). The cats were part of a study of 61 cats admitted to two university clinics over an eight-year period because of signs of CNS disease. The most frequent diseases were feline infectious peritonitis (FIP) (12/27) and suspected viral disease other than FIP (10/27). Typical CSF findings in cats with FIP were a protein concentration of greater than 2 g/L (200 mg/dL) and a white cell count of over 100 cells/microL, which consisted predominantly of neutrophils. In contrast, the CSF of cats with suspected viral disease had a protein concentration of less than 1 g/L (100 mg/dL) and a total white cell count of less than 50 cells/microL. In general, cats with FIP or suspected viral disease were less than four years of age. Neurological signs were usually multifocal in cats with FIP, but focal in cats with suspected viral disease. The CSF findings were variable in five other inflammatory diseases represented. Two cats with protozoan infection had normal CSF total cell counts but abnormal differential counts. The CSF findings were invaluable in differentiating FIP from other causes of inflammatory CNS disease.

A scale to measure microbehaviors of oral contraceptive pill use

The ways in which contraceptive methods are actually used is of increasing interest to researchers, clinicians, and policy makers. Although contraceptive "use" has multiple dimensions, existing indicators measure only one aspect of use or combine unidimensional measures to produce a questionable pastiche. This study uses a subsample of 612 respondents from a larger study of first-time patients at a public-health-department family planning clinic to develop a new measure. Psychometric properties of this measure are examined and discussed.

Reference intervals for feline cerebrospinal fluid: cell counts and cytologic features

Reference intervals for feline CSF cell counts and cytologic variables were determined. Values were derived from 58 adult cats that had normal neurologic examination findings and did not have histologic lesions of the CNS. Effect of age or gender was not apparent for any CSF variable, and no CSF variable was significantly correlated with its corresponding blood value. Total WBC count and neutrophil and eosinophil percentages were positively correlated with the CSF RBC count. Thus, proposed reference intervals for feline CSF were derived from 33 cats with CSF RBC count of less than 31 cells/ul. Data for CSF samples with range between 31 and 1,700 RBC/microliters were also determined. Erythrocyte count was not significantly different in CSF collected, using 20- or 22-gauge spinal needles.

Reference intervals for feline cerebrospinal fluid: biochemical and serologic variables, IgG concentration, and electrophoretic fractionation

Reference intervals are reported for feline CSF biochemical and serologic variables, IgG concentration, and electrophoretic fractionation, derived from 58 clinically normal adult cats that did not have histologic lesions of the CNS. There was no apparent effect of age on any variable. The CSF total protein concentration was significantly (P = 0.012) greater in males than in females, but all other variables were unaffected by gender. The only variable that had a statistically significant correlation with its corresponding blood concentration was IgG. Blood contamination of the CSF affected the following CSF variables: total protein concentration, activities of lactate dehydrogenase and creatine kinase, IgG ratio, and gamma-globulin percentage. The reference intervals proposed for feline CSF were derived from 33 cats with CSF RBC count less than 31 cells/microliters. Reference limits for CSF with 31 to 1,700 RBC/microliters also are reported.

Vestibular syndrome associated with an ependymoma in a cat

An ependymoma was diagnosed in a 4.5-year-old spayed Siamese cat with clinical signs of vestibular disease. Diagnosis was based on history, results of neurologic examination, and the finding of neoplastic cells in CSF. Necropsy revealed an ependymoma arising from the fourth ventricle of the ventricular CNS and involving the left medullary and cerebellar areas.

California serogroup and Powassan virus infection of cats

One hundred and seventy five sera from cats in Ontario, Canada, were tested for hemagglutination inhibition (HI) antibodies to three arboviruses; namely, Powassan (POW) of the Flavivirus serogroup, and Snowshoe hare (SSH) and Jamestown Canyon (JC) viruses of the California (CAL) serogroup. All sera were negative for antibodies to POW virus. Twelve cats possessed CAL serogroup antibodies including 3 with antibodies to SSH alone, 6 with antibodies to JC alone, and 3 with antibodies to both SSH and JC antigens. POW virus was inoculated into seven cats, one intracerebrally and six intravenously. Neurologic signs were not detected in any of the cats. Histologic lesions of a nonsuppurative encephalitis and encephalomyelitis were observed in the intracerebrally inoculated cat and in one of the intravenously inoculated cats, respectively. POW virus was not isolated from the brain or spinal cord of either of these two cats. HI antibodies were detected in the sera of all inoculated animals. HI antibodies were not detected in the CSF of any animal.

Ivermectin toxicosis in a dog

Ivermectin, a broad-spectrum antiparasitic agent, was believed responsible for signs of CNS dysfunction in a dog. Within 2 hours of oral administration of ivermectin, the dog had hind limb ataxia. Neurologic signs progressed rapidly until the dog was in a semicomatose state at admission 20 hours later. The dog improved gradually under supportive care. The ivermectin had been given for suspected endoparasitism. Clinical signs were similar to those reported in dogs with clinical and experimental exposure to ivermectin.

Lymphosarcoma with hypercalcemia and osteolysis in a dog

Lymphosarcoma in a six year old male Doberman pinscher was accompanied by hypercalcemia, generalized osteolysis and renal calcification. Tumor involvement of bone marrow was extensive. The possible pathogenesis of hypercalcemia was thought to be the result of a locally active bone-resorbing factor secreted by the tumor cells.

Effects of dexamethasone on pancreatic tissue and on serum amylase and lipase activities in dogs

The effects of dexamethasone on the pancreas and on pancreatic amylase and lipase activities were determined in clinically normal dogs and in dogs with neurologic disease. Dexamethasone increased serum lipase activity without any histologic damage to the pancreas in either group of dogs. It decreased serum amylase activity in the normal dogs and had a variable effect in dogs with neurologic disease, with or without confirmed pancreatitis. It was suggested that high serum lipase activity in dexamethasone-treated dogs may not be attributable to pancreatitis and that the reasons are still unknown. It was concluded that high serum lipase activity is an unreliable basis for diagnosis of pancreatitis in dogs treated with dexamethasone. The data allowed no conclusion about an additive effect of dexamethasone and neurologic disease causing pancreatitis.

Gastric emptying of liquid meals and pancreatic and biliary secretion after subtotal gastrectomy or truncal vagotomy and pyloroplasty in man

Pancreatic and biliary secretion and gastric emptying rates of a liquid test meal (LTM) were determined in normal persons, in patients with subtotal gastrectomy with gastroduodenostomy (STG-BI) or with gastrojejunostomy (STG-BII), and in patients with truncal vagotomy and pyloroplasty (V&P). In all operated persons, rapid gastric emptying diluted intraluminal contents, with consequent abnormally low concentrations of trypsin and bile salts initially, a pattern that was not corrected by addition of intravenous hormones to the meal stimulus. Trypsin output in V&P's after the LTM was significantly depressed to 40% of normal, but was normal in the STG groups. The delay in reaching normal values for trypsin and bile salt concentrations, was more marked in STG-BII owing to sequestration of secretions in the afferent loop. The low luminal concentrations of digestive secretions for the first 60 to 80 min after a LTM are therefore attributable to rapid gastric emptying in all operated groups, and in V&P to a depressed pancreatic enzyme response also. In STG-BII, afferent loop sequestration exaggerates the delay in attainment of normal intraluminal concentrations. The combined disturbance in STG-BII produces greater abnormalities than seen in STG-BI.