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Mucormycosis is an opportunistic infection caused by fungi of the order Mucorales and Candida is a yeast which is the most common cause of fungal infections in humans. The most commonly known risk factor for these fungal infections is uncontrolled diabetes mellitus (DM), followed by other causes of immunosuppression like neutropenia and corticosteroid therapy. In atypical clinical presentations, all differential diagnosis should be considered, and followed by histopathological and microbiological examination for diagnosis of fungal infections like mucormycosis and candidiasis in uncommon locations. Early diagnosis and combined medical and surgical treatment, along with resolution of the associated risk factors can lead to effective results and good prognosis.
Dermatofibrosarcoma protuberans (DFSP) is a rare, locally aggressive cutaneous sarcoma characterized by a high risk of local recurrence and minimal metastatic potential. However, it remains unresolved whether adjuvant radiotherapy (RT) is necessary in all cases of resectable recurrent disease when complete histologic margin clearance is achieved. A 41-year-old man presented with a localized recurrent DFSP after a prior wide local excision with reportedly negative margins. He underwent Mohs re-excision with 3-cm peripheral margins extending to the fascia, followed by flap reconstruction. Intraoperative frozen-section analysis confirmed microscopically negative margins. No adjuvant RT or systemic therapy was administered. Over a 4-year follow-up period, including serial MRI, no evidence of further recurrence or metastasis was noted. This case illustrates durable local control of recurrent truncal DFSP achieved solely through Mohs re-excision with confirmed negative margins and no adjuvant therapy. These findings indicate that durable oncologic control can be achieved through meticulous re-excision alone, and escalation to adjuvant RT is not invariably required in carefully selected patients if negative margins are reliably secured. Additionally, flap reconstruction enabled wide resection while optimizing cosmesis and function compared with skin grafting. Therefore, potential treatment-related morbidity can be avoided without compromising oncologic outcomes. Mohs micrographic surgery re-excision with confirmed negative margins achieved sustained local control over 4 years in recurrent truncal DFSP. The outcome supports individualized surgical management without adjuvant RT in selected resectable recurrent cases. Margin adequacy might serve as the primary determinant of local control while avoiding long-term radiation morbidity.
Human tumors likely differ in their mitotic ages, reflecting how many divisions elapse between the final tumor progenitor cell and surgical removal. We used a rapidly fluctuating CpG (fCpG) methylation clock to infer relative endometrial adenocarcinomas (EAC) mitotic ages. Experimentally, young tumors initiated from single cells show low-diversity, high-variance fCpG distributions with trimodal peaks near 0%, 50%, and 100%, reflecting inherited progenitor methylation states. fCpG methylation becomes polymorphic with divisions, and older tumors exhibit higher diversity, lower variance, and unimodal distributions centered around 50%. Mitotic ages varied across EAC samples. Synchronous hyperplasia and invasive regions generally shared similar ages, and primary-metastatic EAC pairs showed both synchronous and stepwise progression. The Cancer Genome Atlas (TCGA) EACs also showed variable mitotic ages: younger tumors were enriched for proliferation pathways, whereas older tumors showed more immune infiltration, immune-pathway activation, and evidence of T-cell exhaustion. These results show that human tumors can be ranked by mitotic age and suggest that the growth of older cancers is restrained by immune surveillance. © 2026 The Author(s). The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.
As machine-learning models for vocal pathology advance, their performance is increasingly constrained not by modelling techniques but by the taxonomic structures used to define the classification task itself. Conventional clinical frameworks, while grounded in diagnostic practice, often reflect conceptual groupings that do not map cleanly onto the acoustic patterns learned by modern Voice AI systems-contributing to the persistent performance gap between multi-class and binary detection tasks. Motivated by this mismatch, we introduce an alternative strategy: deriving a taxonomy from data-driven acoustic relationships rather than prescriptive clinical categories, with the goal of establishing a more model-aligned and generalisable foundation for voice disorder classification. We developed CarLab 2025, a novel data-driven classification framework derived from model confusion patterns. We conducted comprehensive experiments comparing its performance against existing clinical taxonomies, including the hierarchical USVAC 2025 framework, as well as Compton 2022, da Silva Moura 2024, and Za'im 2023, across multiple vocal tasks, features, and model architectures. We evaluated both in-domain performance and cross-database generalisation, including experiments with multi-task learning and targeted data injection. CarLab 2025 achieved superior in-domain classification accuracy compared to established clinical taxonomies, with balanced accuracy reaching 67.20% compared to 61.03% for the best-performing clinical framework. For out-of-domain generalisation, models trained with structured taxonomies consistently outperformed those trained with narrow, single-disorder labels, and training on a diverse set of vocal tasks proved more effective for cross-database performance than relying on a single task. Multi-task learning offered no advantage over single-task training, and while injecting a small amount of data from target domains significantly boosted binary detection accuracy, this improvement did not consistently translate to multi-class recall. Our experiments established a baseline performance exceeding that obtained with existing clinical classification frameworks by aligning more closely with acoustic manifestations of disorders. We further show that exposure to varied recording conditions is crucial for binary generalisation, while robust multi-class generalisation will require substantially more diverse multi-source training data. The results provide a clear, evidence-based path toward developing more robust and generalisable models for vocal pathology detection.
Lower gastrointestinal bleeding (LGIB) in older adults is most commonly caused by diverticular disease. Concomitant pathology may be encountered during evaluation, particularly in patients with multiple comorbidities. A 78-year-old man presented with painless hematochezia and hypovolemic shock while receiving clopidogrel. After stabilization, colonoscopy identified a sigmoid diverticulum with an adherent clot, which was treated with injection and clipping. During the same examination, an ulcerated ileocecal valve was noted. Retrograde single-balloon enteroscopy was subsequently performed, demonstrating terminal ileal ulceration consistent with Crohn's disease and an incidental Meckel's diverticulum. Hemorrhage control was achieved endoscopically and attributed to diverticular bleeding. Further evaluation was undertaken based on the ileocecal finding, allowing direct assessment of the terminal ileum. In this case, targeted evaluation, prompted by a focal ileocecal abnormality, identified silent Crohn's disease and an incidental Meckel's diverticulum; while unrelated to the bleeding source, their recognition informed subsequent management and surveillance.
Burr cell hemolytic anemia is diagnosed through the identification of burr cells and thrombocytopenia on a peripheral blood smear, in conjunction with an increased reticulocyte count and elevated serum bilirubin levels. Burr cells, referred to as echinocytes, are a type of red blood cell that features short, evenly spaced spicules and a preserved central pallor. This condition is commonly associated with liver disorders or advanced kidney disease. Although the occurrence of burr cell hemolytic anemia in conjunction with varicose veins is rare, it may be indirectly related to liver damage. In this case report, we discuss a patient with congenital varicose veins who experienced tubal abortion and burr cell hemolytic anemia.
The Runner-type peanut (Arachis hypogaea L.) cultivar 'Tifguard' carries an introgressed chromosomal segment on chromosome A09 from A. cardenasii that confers resistance to root-knot nematode (RKN). Despite this, a proportion of 'Tifguard' plants show RKN symptoms, which could plausibly be attributed to seed mixture or outcrossing. However, recent work has shown that cultivated peanut exhibits surprisingly frequent large-scale chromosomal instability (1-5%), raising the possibility that resistance loss could arise from spontaneous structural genomic change. To test these possibilities, we grew foundation seed in an RKN-infested field and collected symptomatic and asymptomatic plants. Lineages derived by single-seed descent were genotyped using the Axiom Arachis 48K SNP array v2 and whole-genome sequencing. Symptomatic lineages lacked the A. cardenasii introgression on chromosome A09 and instead carried the complete endogenous A. hypogaea A09 region at the expected dosage. There was no evidence of large-scale homoeologous exchange, deletion, or other genomic instability affecting this chromosome. Most susceptible plants were closely related to resistant 'Tifguard' but lacked the A09 introgression, with a smaller proportion assignable to known nematode-susceptible cultivars, implicating seed mixture with a possible contribution from cross-pollination rather than genomic instability. Because resistance depends on a single major-effect segment, rare events have disproportionate phenotypic impact, placing high demands on genetic purity. For important traits conferred by major loci, marker-based testing across seed-increase stages could verify trait retention directly, and is increasingly practical as marker costs decline.
To prospectively evaluate the influence of multiparametric magnetic resonance imaging (mpMRI) quality, as assessed by the Prostate Imaging Quality (PI-QUAL) score, on diagnostic accuracy in men undergoing prostate biopsy after external mpMRI at a tertiary referral center. From June 2024 to July 2025, a total of 246 consecutive patients referred for prostate biopsy after external mpMRI were prospectively enrolled. All patients underwent systematic biopsy with targeted biopsy when indicated. External mpMRI scans were centrally reviewed by expert uro-radiologists blinded to clinical and pathological data. Image quality and lesion grading were reassessed using PI-QUAL v2 and Prostate Imaging Reporting and Data System (PI-RADS) v2.1. Accuracy for clinically significant prostate cancer (csPCa; International Society of Urological Pathology [ISUP] grade ≥2) was assessed using receiver operating characteristic-derived area under the curve AUC before and after review, stratified by PI-QUAL (1-2 vs 3). Median age and prostate-specific antigen (PSA) were 66.5 years (interquartile range [IQR] 61-73) and 6.6 ng/mL (IQR 4.8-9.7), respectively, and csPCa was detected in 128 patients (52%). After review, 49 (20%), 113 (46%), and 84 (34%) mpMRI scans were classified as PI-QUAL 1, 2, and 3, respectively. The proportion of indeterminate PI-RADS 3 findings was 27% for PI-QUAL 1, 15% for PI-QUAL 2, and 8% for PI-QUAL 3. PI-QUAL 3 scans demonstrated greater diagnostic accuracy than PI-QUAL 1-2 (AUC 0.79 vs 0.66, P = 0.01). Central review improved csPCa detection in both PI-QUAL 1-2 (AUC 0.63 vs 0.78, P < 0.01) and PI-QUAL 3 (AUC 0.77 vs 0.89, P < 0.01) scans. High-quality mpMRI achieved approximately 15% higher diagnostic accuracy for csPCa and were associated with a lower prevalence of indeterminate findings than were low-quality MRI scans; centralized expert review reclassified nearly half of PI-RADS assessments. These findings support upfront high-quality mpMRI acquisition and PI-QUAL-based quality control to optimize diagnosis and reduce unnecessary procedures.
Recurrent neonatal infection caused by the same bacterial lineage across pregnancies is rarely documented. We describe two preterm siblings born one year apart who developed Escherichia coli sepsis caused by clonally related strains. Two female infants were born preterm, 1 year apart, at 26 weeks and 4 days and 30 weeks and 3 days of gestation, respectively, following prolonged premature rupture of membranes. Both infants were evaluated for early-onset sepsis at birth with blood cultures and administered empiric ampicillin and gentamicin; initial blood cultures were sterile, and antibiotics were discontinued after 24 h. At 7 days of age, each infant developed new clinical signs of infection, and both were diagnosed with E. coli bacteremia. Both infants recovered after treatment with intravenous antibiotics. Whole-genome sequencing identified the isolates as O15:K52:H18, sequence type 69 (ST69), differing by only a few single nucleotide polymorphisms. These cases suggest recurrent vertical transmission of a pathogenic E. coli lineage leading to neonatal infection arising just beyond the immediate newborn period.
Intravesical instillation of Mycobacterium bovis bacillus Calmette-Guérin (BCG) was first used to treat bladder cancer in 1976. Since then, it has become a common therapy for non-muscle invasive bladder cancer. A live, attenuated mycobacterium, M. bovis BCG causes infectious complications in approximately 1% of patients. These infections can involve various anatomic sites and have a range of presentations. Diagnosis may require several testing modalities, and treatment typically involves multiple antimicrobials for a long duration. We report three cases of M. bovis BCG infection following intravesical BCG instillation for the treatment of bladder cancer. The patients are men ranging in age from 71 to 83 years old. One had a ruptured mycotic aneurysm of the aorta, another had a presumed anaphylactic reaction, and the final had a bone marrow infection. Isolation of BCG was achieved through mycobacterial blood culture in two cases and also through mycobacterial culture of bone marrow and hematoma aspirate. Nucleic acid amplification testing for Mycobacterium tuberculosis complex (of which BCG is a member) was utilized in two cases, and histologic examination identified granulomas in one case. Two of the patients received mycobacterial treatment, including rifampin, isoniazid, ethambutol, and linezolid. One patient remains living over 3 years after infection, one died despite treatment, and one died from unrelated causes. These cases highlight the diversity of BCG infection symptoms and sites and the various laboratory testing modalities that can inform diagnosis and treatment.
Giant visceral artery aneurysms are exceedingly rare and carry a high risk of rupture. Patients with liver cirrhosis, portal hypertension, or connective tissue disorders are at an increased risk. Timely recognition and surgical intervention are critical to prevent life-threatening complications. A 66-year-old male with hepatitis B-related cirrhosis presented after blunt abdominal trauma. Imaging revealed a well-defined, contrast-enhanced hyperdense lesion in the mid-splenic artery, consistent with a giant aneurysm, along with a small hypodense liver lesion. Due to the aneurysm's size and rupture risk, surgical resection of the splenic artery aneurysm (SAA) with splenectomy was performed via midline laparotomy, along with a liver wedge biopsy. Pathology confirmed a true SAA with wall calcification and atherosclerosis, an unremarkable spleen, reactive lymph nodes, and mild cirrhosis without malignancy. Postoperatively, the patient recovered well with an improved platelet count, stable liver function, and continued hepatitis B management. Giant SAAs may be asymptomatic or detected incidentally, yet they pose a significant rupture risk, particularly in cirrhotic patients. Surgical resection remains the definitive treatment, reducing the risk of catastrophic hemorrhage and improving clinical outcomes. Prompt diagnosis and early surgical management of giant SAAs are essential, especially in high-risk patients, to prevent rupture and achieve favorable postoperative recovery.
TCF7L2 (OMIM:602228; HGNC:11641) is a transcription factor and critical effector of the Wnt/β-Catenin pathway. In 2021, 11 pediatric patients with mono-allelic predicted loss-of-function (pLOF) TCF7L2 variants and syndromic features were observed. Characterization of patients with pLOF TCF7L2 variants and neurodevelopmental features - herein referred to as TCF7L2-related neurodevelopmental disorder (TRND) - is urgently needed. We leveraged multiple methods (GeneMatcher, DECIPHER, literature review, public/private repositories) to identify an international cohort of 76 patients with pLOF TCF7L2 variants and neurodevelopmental features and phenotypically characterized them. We also retrospectively searched for an independent cohort of adults with pLOF TCF7L2 variants (n = 11) from 60,000+ PennMedicine BioBank (PMBB) patients. Among 76 patients with pLOF TCF7L2 variants, speech delay (95.3%), craniofacial dysmorphisms (73.3%), ophthalmologic conditions (65.5%), autism (62.1%), and orthopedic abnormalities (52.6%) were most commonly observed. Phenotypic differences did not cluster by variant type or genomic locus. Among PMBB patients, an association of nominal significance with type 2 diabetes with renal manifestations (OR = 5.8; p-value = 0.03) was detected, warranting further investigation. This represents the most comprehensive characterization to date of TRND, a novel neurodevelopmental disorder, defining its genotypic and phenotypic spectrum. We opened a Simons Searchlight natural history study (https://www.simonssearchlight.org/research/what-we-study/tcf7l2/) to enhance understanding of this condition.
Paenibacillus species are rod-shaped, gram-variable, endospore-forming, environmental bacteria. Once classified within Bacillus spp., it was reclassified based on 16S rRNA sequencing. Paenibacillus spp. has rarely been found to be pathogenic in humans; however, recent reports have been described in immunocompromised patients. A 60-year-old male with past medical history of hypertension, hyperlipidemia, atrial fibrillation, and bicuspid aortic valve presented to an outside hospital for 3 days of chest pain without associated symptoms. He was transferred to our institution after computed tomography (CT) demonstrated fluid around the aortic root concerning for aortic pseudoaneurysm. Admission and follow-up blood cultures were negative. He was started on ceftriaxone and vancomycin and underwent aortic root repair. Intraoperative cultures grew gram-indeterminate bacilli identified as Paenibacillus pueri by 16S broad-range PCR at an outside institution. Initial pathogen identification was complicated without discernible morphological differences between Paenibacillus spp. and Bacillus spp. Final identification often relies on molecular methods. Previous cases utilized amoxicillin-clavulanate or trimethoprim-sulfamethoxazole, with resistance demonstrated to penicillins and clindamycin. In our case, doxycycline was chosen based on limited susceptibility profiles and considering antibiotic side effect profiles. This is the third documented human case of Paenibacillus pueri infection. Paenibacillus spp. infections have varied clinical presentations, typically described in immunocompromised patients. This case demonstrates the difficulties in identifying Paenibacillus pueri. While rare, Paenibacillus spp. has been occasionally implicated in human disease. Even in immunocompetent patients, suspicion for true pathogens should remain high with repeated isolation on separate specimens.
Glioblastoma (GB), or grade IV astrocytoma, is the most prevalent primary tumor of the central nervous system (CNS). This systematic review aimed to investigate the efficacy and tolerability of virotherapy treatment for recurrent and progressive glioblastoma patients. We also examined recent progress in preclinical and clinical trials, and future perspectives. We developed a search strategy using Medical Subject Headings (MeSH) terms and keywords. Inclusion criteria were English language published and ongoing clinical trials that involved patients undergoing virotherapy for glioblastoma. We searched through PubMed, Embase, Ovid, Scopus, Cochrane databases and https://Clinicaltrials.gov from inception until May 9th, 2025. Two independent reviewers screened records, extracted data, and assessed risk of bias (ROB2). No meta-analysis was performed due to heterogeneity. PROSPERO CRD420250636791. Of 975 records screened, 43 studies (24 published, 19 ongoing) enrolled 462 virotherapy patients. Most common adverse events: headache (n=145), fatigue (n=83) and fever (n=78). Risk of bias was moderate to serious in most studies. We encountered several limitations, including high heterogeneity, reporting inconsistencies, and small sample sizes. Most patients experienced disease stabilization. However, objective response and complete remission occurred infrequently. A small proportion of patients achieved long-term survival, suggesting that virotherapy could be effective in specific subgroups. While oncolytic virus therapy is generally tolerated, neurotoxicity remains the most significant risk. Adverse effects were mostly Grade 1-2. Some trials (notably with HSV-1 or NDV) had severe events. Symptoms were often transient and manageable but need closely monitoring. However, the observed heterogeneity, limited data standardisation, and lack of randomized controlled trials, besides tumor heterogeneity, antiviral immunity and immunosuppressive microenvironment, necessitate further research to identify predictive biomarkers and optimize therapeutic protocols. We also suggest further trials on novel delivery methods, such as the nanoparticles, to enhance blood-brain barrier (BBB) penetration.
The multifactorial neurodegenerative disease known as Alzheimer's disease (AD) is typified by amyloid-β aggregation, tau hyperphosphorylation, neuroinflammation, and synaptic dysfunction, as well as progressive cognitive decline. Due to the limited effectiveness of conventional therapeutic approaches, multi-target agents must be investigated. A traditional Ayurvedic polyherbal formulation, Triphala contains a wide range of bioactive phytochemicals that have been shown to have neuroprotective effects. The molecular targets of Triphala phytocompounds related to AD pathology were clarified in the current study using a network pharmacology approach. BindingDB and SwissTargetPrediction were used to predict the putative protein targets of 18 phytocompounds, yielding 54 distinct targets. The STRING database was used to build a protein-protein interaction (PPI) network, which Cytoscape was then used to analyse. The following 7 important hub genes were identified using topological parameters (degree, betweenness, closeness centrality): BCL2, CASP3, MMP9, JUN, NFKB1, PTGS2, and ESR1. Potential mechanistic overlap was highlighted by the significant involvement of 20 genes in AD-related pathways and 30 genes in the lipid and atherosclerosis pathway, according to gene enrichment analysis using KEGG. Synaptic plasticity, oxidative stress response, neuroinflammatory signalling, and apoptosis regulation are the main functions of these genes. The integrative analysis highlights Triphala's polypharmacology mechanism and raises the possibility that it could be used as a multi-target therapeutic candidate for AD. This study offers a logical foundation for additional in vitro and in vivo validation of Triphala-derived neurotherapeutics as well as a systems-level framework for comprehending herb-compound-gene-disease interactions. The online version contains supplementary material available at 10.1007/s40203-026-00704-6.
The INHAND Project is a joint initiative of the societies of toxicologic pathology from Europe, the United Kingdom, Japan, and North America to standardize diagnostic nomenclature and criteria used in toxicologic studies. The INHAND initiative includes recommended nomenclature for evaluating histologic specimens from nonclinical studies involving laboratory animals including rodents, non-human primates, dogs, minipigs, rabbits, and fish. Specific terminology and criteria are derived from the consensus opinions of senior toxicologic pathologists and subject matter experts who have expertise in the different species of interest. The standardized nomenclature presented in this document is also available electronically on the internet (http://www.goreni.org/). Sources of material included government databases, including the Registry of Tumors in Lower Animals (RTLA), academia, and industrial laboratories throughout the world. This introduction provides context for 14 chapters, arranged by organ system, that define the INHAND nomenclature and diagnostic criteria for fish used in nonclinical studies. Additionally, the current introductory chapter describes both general features of INHAND methodology as well as elements characteristic of toxicologic fish studies. The latter includes fish study design and conduct; euthanasia, sampling, the histologic processing of fish tissues, and a general approach to evaluating fish studies.
Anaplastic thyroid cancer (ATC) is a rare malignancy with a poor prognosis. A substantial subset harbors the BRAF V600E mutation, enabling targeted therapy with dabrafenib and trametinib. We present the case of a 56-year-old woman with BRAF V600E-mutated ATC who developed acute airway obstruction and asphyxia-induced cardiac arrest. Due to critical tracheal stenosis, surgery was performed in combination with targeted therapy using dabrafenib plus trametinib. Total thyroidectomy successfully relieved tracheal compression and enabled continued treatment. Follow-up with a computed tomography examination demonstrated complete regression of nodal metastases, and subsequent lymph node dissection was performed, confirming the absence of residual disease. After about 1 year of follow-up, the patient remains disease-free postoperatively, illustrating the importance of molecular testing, multidisciplinary management, and a multimodal treatment strategy for ATC. Approximately one-third of cases of ATC may have the BRAF V600E mutation and thus be sensitive to treatment with dabrafenib plus trametinib. This is a paradigm shift in the treatment of ATC, where surgery should be adapted to the mutational status of the tumor, even if the cancer is metastatic and locally advanced. In selected patients, combining surgery with BRAF/MEK inhibition may transform ATC from an invariably fatal disease into a potentially curable condition.
Low back pain (LBP) is a leading global cause of disability, with lumbar paraspinal muscle degeneration playing a key pathophysiological role. Lumbar multifidus muscle (LMM) atrophy, detectable on magnetic resonance imaging (MRI) as fatty infiltration, is closely associated with degenerative lumbar pathology. However, the relationship between LMM fat infiltration and co-existing degenerative changes - disc herniation, intervertebral disc degeneration (IVDD) and facet joint degeneration (FJD) - requires further characterisation. This hospital-based cross-sectional study was conducted from March 2023 to February 2024. Eighty-six patients (38 males, 48 females; age 20-60 years) with clinically diagnosed LBP of ≥ three month-duration underwent 1.5 Tesla MRI lumbar spine in Assam Medical College and Hospital (AMCH), Dibrugarh, India. Lumbar multifidus muscle fat infiltration at the L4/L5 mid-disc level was graded using Goutallier's classification (Grades 0-4). Intervertebral disc degeneration was graded using Pfirrmann's system and facet joint changes by Pathria's grading. Statistical analysis was performed using Fisher's exact test. The majority of patients had Grade 2 LMM fat infiltration (45.34%), followed by Grade 3 (23.26%), Grade 1 (18.61%), Grade 4 (8.14%) and Grade 0 (4.66%). Disc herniation was present in 67.44% of patients, with Grade 3 being the most frequently seen (36.04%). A progressive increase in disc herniation grade was observed with increasing LMM atrophy grade. Pfirrmann Grade 3 IVDD was most prevalent (27.90%). Grade 1 facet joint degeneration predominated (50.0%). Higher grades of LMM fat infiltration correlated significantly with higher grades of IVDD and FJD (p < 0.05). MRI-based qualitative assessment of LMM fat infiltration using Goutallier's grading is a reliable, clinically practical method that should be incorporated into routine lumbar spine reporting. Increasing LMM atrophy correlates significantly with progressive degenerative changes including disc herniation, IVDD and FJD. Targeted lumbar muscle rehabilitation should be considered as an integral component of LBP management.
Simple hepatic cysts are benign and usually asymptomatic; however, they can rarely develop serious complications, such as hepatoduodenal fistula, due to infection, cyst size, or mechanical pressure. A 68-year-old male presented with fever, hematochezia, and severe right upper quadrant pain. Imaging revealed a 10 × 12 cm segment V-VII hepatic cyst with an air-fluid level, and endoscopy showed a fistulous opening in the second duodenum adjacent to a necrotic diverticulum. After stabilization, laparotomy confirmed a hepatoduodenal fistula; a 2 cm opening was closed with an omental patch, the cyst was deroofed, and a drain was placed, resulting in excellent recovery. This rare hepatoduodenal fistula arose from an infected simple hepatic cyst (pathology: cuboidal epithelium; negative Echinococcus serology), driven by inflammation and mechanical stress. Percutaneous drainage failed due to enteric communication; surgery was definitive. Infected simple hepatic cysts can rarely progress to a hepatoduodenal fistula with significant morbidity, but prompt diagnosis, resuscitation, antibiotics, and definitive surgical repair can result in full recovery.
Olmesartan-induced enteropathy is an uncommon but important cause of severe chronic diarrhea and weight loss that can mimic celiac disease and infiltrative gastrointestinal disorders. We report a 71-year-old man on long-term olmesartan who presented with months of diarrhea, nausea/vomiting, profound weakness, and ∼100 pounds of unintentional weight loss. Esophagogastroduodenoscopy demonstrated duodenal villous blunting with lamina propria lymphoplasmacytic inflammation and rare periodic acid-Schiff-positive macrophages. An empiric 3-week gluten-free diet trial was ineffective. Celiac serologies, infectious stool studies, and HIV testing were negative. Laboratory evaluation revealed anemia, elevated creatinine, hypercalcemia, and a gamma gap; serum and urine protein electrophoresis showed an M-protein, and bone marrow biopsy confirmed multiple myeloma. Repeat duodenal biopsies again showed villous blunting, while Congo red staining was negative, arguing against gastrointestinal amyloidosis. Olmesartan-induced enteropathy was favored; olmesartan was discontinued and budesonide was started. Within 1 month, gastrointestinal symptoms resolved and the patient gained 20 pounds. Recognition of this drug effect is critical, particularly when concurrent hematologic disease raises concern for infiltrative etiologies.