Objectives To present a case of human monocytic ehrlichiosis (HME) that was complicated by macrophage activation syndrome (MAS), also known as secondary hemophagocytic lymphohistiocytosis (sHLH).Methods Data was collected from patient's electronic medical records at the University of Alabama at Birmingham. The patient is a part of a larger cohort of patients with all-cause MAS treated at our center.Case A 63 year old renal transplant recipient male on maintenance immunosuppressive therapy presented with high grade fever, leukopenia, thrombocytopenia and elevated transaminases and initially met clinical criteria for severe sepsis. On further investigation, clinical and laboratory criteria for MAS were met. He was treated with a combination of doxycycline for HME and a novel combination of anakinra (interleukin-1 receptor antagonist), and high dose corticosteroids. The discussion focuses on clinical presentation, pathogenesis and treatment of MAS with an emphasis on MAS secondary to HME.Conclusion Macrophage activation syndrome or sHLH is a dysfunctional, hyperactive and potentially fatal immune system response that results in multi-organ dysfunction. With increasing incidence of Ehrlichia chaffeensis as an emerging pathogen, clinicians should be aware of this fulminant and potentially fatal complication of HME.

Diagnostic CytopathologyVolume 43, Issue 3 p. 268-270 Letter to the Editor Locally advanced thymic carcinoma with direct pericardial extension and atrial clot diagnosed with endoscopic ultrasound: A case report Jatinder Goyal M.D., Jatinder Goyal M.D. Department of Medicine, University of Alabama at Birmingham, Birmingham, AlabamaSearch for more papers by this authorAnshum Goel M.D., Anshum Goel M.D. Department of Medicine, University of Alabama at Birmingham, Birmingham, AlabamaSearch for more papers by this authorAli S. Khan M.D., Ali S. Khan M.D. Department of Gastroenterology, University of Alabama at Birmingham, Birmingham, AlabamaSearch for more papers by this authorMohamad A. Eloubeidi M.D., Corresponding Author Mohamad A. Eloubeidi M.D. Division of Gastroenterology and Hepatology, School of Medicine, American University of Beirut, LebanonCorrespondence to: Mohamad A. Eloubeidi, Division of Gastroenterology and Hepatology, American University of Beirut School of Medicine, P.O. Box 11–0236, Riad El Solh 110 72020, Beirut, Lebanon. E-mail: [email protected]Search for more papers by this author Jatinder Goyal M.D., Jatinder Goyal M.D. Department of Medicine, University of Alabama at Birmingham, Birmingham, AlabamaSearch for more papers by this authorAnshum Goel M.D., Anshum Goel M.D. Department of Medicine, University of Alabama at Birmingham, Birmingham, AlabamaSearch for more papers by this authorAli S. Khan M.D., Ali S. Khan M.D. Department of Gastroenterology, University of Alabama at Birmingham, Birmingham, AlabamaSearch for more papers by this authorMohamad A. Eloubeidi M.D., Corresponding Author Mohamad A. Eloubeidi M.D. Division of Gastroenterology and Hepatology, School of Medicine, American University of Beirut, LebanonCorrespondence to: Mohamad A. Eloubeidi, Division of Gastroenterology and Hepatology, American University of Beirut School of Medicine, P.O. Box 11–0236, Riad El Solh 110 72020, Beirut, Lebanon. E-mail: [email protected]Search for more papers by this author First published: 11 December 2014 https://doi.org/10.1002/dc.23172 Conflict of Interest: The authors report no conflict of interest. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1Rashid OM, Cassano AD, Takabe K. Thymic neoplasm: A rare disease with a complex clinical presentation. J Thorac Dis 2013; 5: 173–183. 2Strollo DC, Rosado de Christenson ML, Jett JR. Primary mediastinal tumors. Part 1: Tumors of the anterior mediastinum. Chest 1997; 112: 511–522. 3Rosai J, Sobin L. Histological classification of tumours of the thymus. Histological typing of tumours of the thymus. Berlin: Springer; 1999. p 5–7. 4Khoury T, Chandrasekhar R, Wilding G, Tan D, Cheney RT. Tumour eosinophilia combined with an immunohistochemistry panel is useful in the differentiation of type B3 thymoma from thymic carcinoma. Int J Exp Pathol 2011; 92: 87–96. 5Kojika M, Ishii G, Yoshida J, et al. Immunohistochemical differential diagnosis between thymic carcinoma and type B3 thymoma: Diagnostic utility of hypoxic marker, GLUT-1, in thymic epithelial neoplasms. Mod Pathol 2009; 22: 1341–1350. 6Kornstein MJ, Rosai J. CD5 labeling of thymic carcinomas and other nonlymphoid neoplasms. Am J Clin Pathol 1998; 109: 722–726. 7Nakagawa K, Matsuno Y, Kunitoh H, et al. Immunohistochemical KIT (CD117) expression in thymic epithelial tumors. Chest 2005; 128: 140–144. 8Kramer H, van Putten JW, Post WJ, et al. Oesophageal endoscopic ultrasound with fine needle aspiration improves and simplifies the staging of lung cancer. Thorax 2004; 59: 596–601. 9Klapman JB, Logrono R, Dye CE, Waxman I. Clinical impact of on-site cytopathology interpretation on endoscopic ultrasound-guided fine needle aspiration. Am J Gastroenterol 2003; 98: 1289–1294. 10Eloubeidi MA, Tamhane A, Jhala N, et al. Agreement between rapid onsite and final cytologic interpretations of EUS-guided FNA specimens: Implications for the endosonographer and patient management. Am J Gastroenterol 2006; 101: 2841–2847. 11Larghi A, Noffsinger A, Dye CE, Hart J, Waxman I. EUS-guided fine needle tissue acquisition by using high negative pressure suction for the evaluation of solid masses: A pilot study. Gastrointest Endosc 2005; 62: 768–774. 12Nonaka T, Tamaki Y, Higuchi K, et al. The role of radiotherapy for thymic carcinoma. Jpn J Clin Oncol 2004; 34: 722–726. Volume43, Issue3March 2015Pages 268-270 ReferencesRelatedInformation

Isolated gastroduodenal Crohn’s disease (GCD) is extremely rare. We hereby report a unique case of isolated GCD masquerading as apparent linitis plastica in an elderly man. A 78-year-old Caucasian man with an insignificant past medical history was referred to our gastroenterology service with intractable nausea and vomiting of gradually increasing frequency over 2 years. [Table 1] summarizes the results of his laboratory tests.

Background: The diagnostic yield of capsule endoscopy is vulnerable to inadequate visualization related to residual bile or chyme remaining in the lumen despite intestinal lavage. It has been challenging to determine the optimal lavage preparation of the bowel and patient diet before capsule endoscopy, as well as the timing of the procedure, because no well-accepted, validated grading system for assessing the quality of intestinal lavage before capsule endoscopy is available. There remains no consensus on the reliability of qualitative, quantitative, or computer-derived assessments of the quality of preparation for capsule endoscopy. This study evaluates intra-observer and interobserver agreement for a previously validated scale.Materials and methods: The digital images of 34 patients who underwent capsule endoscopy were independently reviewed by two blinded physicians according to a previously validated grading scale. One of the physicians reviewed and graded the patients a second time. The quality of the bowel luminal preparation was assessed with a qualitative parameter (fluid transparency) and amore quantitative parameter (mucosal invisibility) for each of three small-intestinal segments, and an overall small-bowel score for each parameter was assigned as well. A weighted kappa coefficient was used to calculate intra-observ-er (observer 1A and 1B) and interobserver (observer 1A and observer 2) agreement. A kappa value of 0.60 or more suggests strong agreement, 0.40 to 0.60 moderate agreement, and less than 0.40 poor agreement.Results: The intra-observer weighted kappa index for both fluid transparency and mucosal visibility was 0.52, which is consistent with moderate agreement. The interobserver weighted kappa indices for fluid transparency and mucosal invisibility were 0.29 and 0.42, respectively, demonstrating suboptimal interobserver agreement. The individual segment interobserver kappa indices were better for mucosal visibility (0.52, 0.39, and 0.47 for small-bowel segments 1, 2, and 3, respectively) than for fluid transparency (0.18, 0.38, and 0.31).Conclusions: The proposed grading scale for assessing the quality of preparation for capsule endoscopy has inadequate interobserver and intra-observer agreement. Capsule endoscopy preparation grading scales that focus more on quantitative than on qualitative assessment may demonstrate more reliable performance characteristics. Optimizing the quality of preparation and diagnostic yield of capsule endoscopy will first require the development of a well-validated grading scale.