Epstein-Barr virus (EBV) infection is mostly subclinical and resolves spontaneously without complications. Gastroenterology involvement usually manifests as asymptomatic liver enzymes elevation. We report a new case of acute pancreatitis complicating EBV infection and review the literature. EBV-associated acute pancreatitis is rare, usually develops in the setting of clinically clear EBV infection, occurs mostly in children and young adults, has mild-to-moderate severity, and has excellent prognosis with conservative management. It should be suspected when patients with an EBV infection picture develop unexplained abdominal pain.

Background: Signet ring cell carcinoma (SRCC) is a rare, highly malignant adenocarcinoma that generally involves the stomach; ileal involvement is uncommon. Crohn disease (CD) is associated with long-standing inflammation that may predispose to small intestine adenocarcinoma. Case Report: A 67-year-old male with ileal CD since age 23 years, maintained in remission by mesalamine, presented with mild intermittent attacks of abdominal cramping, an increase in bowel movements from 3 to 5 daily, and bloating for 3 months. Computed tomography enterography with contrast enhancement demonstrated 2 segments of ileal wall thickening. Colonoscopy performed 7 years prior was unremarkable. The patient received oral prednisone with mild symptomatic improvement; he declined biologics. Ileocolonoscopy 1 month later revealed a nontraversable terminal ileal stricture 15 cm from the ileocecal valve. Biopsy demonstrated signet ring cells infiltrating the lamina propria. The patient underwent laparoscopic ileocecectomy and ileocolic anastomosis. Histopathology of a 2.5-cm ileal mass showed poorly differentiated adenocarcinoma with mucin production and signet ring cell features. One metastatic mesenteric lymph node was identified. Adjuvant chemotherapy was initiated. Conclusion: This case of metastatic ileal SRCC occurred in the setting of long-standing, clinically controlled CD. Although the absolute risk of small-bowel adenocarcinoma in CD is low, active surveillance for small-bowel adenocarcinoma in patients with longstanding CD may be prudent, given the overlapping symptomology of SRCC and CD, the aggressiveness of SRCC, and the association of SRCC with subclinical inflammation.

The P2Y12 inhibitor, ticagrelor, has been shown to prevent thrombotic events and hence, improve morbidity and mortality in patients with acute coronary syndrome following coronary artery stent placement. Despite many clinical benefits, ticagrelor has been associated with several adverse effects, including dyspnea, easy bruising, and gastrointestinal bleeding. We report the case of a 67-year-old patient with an acute coronary artery syndrome requiring percutaneous coronary artery intervention with stenting who developed ticagrelor-induced diarrhea. The patient’s ticagrelor medication was replaced with clopidogrel, and his diarrhea completely resolved within one week with no complications observed at his one-month follow-up visit. Clinicians should be aware of this adverse effect of ticagrelor so as to guide them toward possible underlying etiologies and appropriate workup of chronic diarrhea.

INTRODUCTION: Glycogen hepatopathy (GH), a rare glycogen storage disease caused by genetic or acquired overactivation of hepatic glycogen synthesis enzymes, can mimic non-alcoholic fatty liver disease (NAFLD). We describe a case of biopsy proven GH in an adult with Type 1 DM (T1DM). Similar to cases described in the current literature, our case not only portrays the challenges faced by physicians when diagnosing this condition, but also the importance of distinguishing this from NAFLD. CASE DESCRIPTION/METHODS: A 33-year-old Honduran woman with a 25-year history of T1DM complicated by gastroparesis, multiple episodes of DKA and hypoglycemia, and recurrent pancreatitis was referred for abnormal liver enzymes. Family history was negative for liver disease. There was no history of alcohol or recreational drug use. Patients medications included insulin and thyroxine. Physical exam showed hepatomegaly but no stigmata of chronic liver disease. AST and ALT had ranged from 100’s to over 7000 while ALP was elevated to over 400. Albumin, Total bilirubin, platelets, INR, eosinophils, viral hepatitis panel, ANA, smooth muscle AB, LKM Ab, celiac serologies, ceruloplasmin, alpha 1 antitrypsin, iron studies, and acetaminophen levels were all normal. An abdominal ultrasound showed “fatty liver” and an atrophic pancreas. CT abdomen showed hepatomegaly. CBD was found to be normal on EUS and MRCP. A liver biopsy demonstrated glycogenotic hepatocytes. DISCUSSION: GH is frequently misdiagnosed as NAFLD, a more common liver disease that is also associated with diabetes. While GH is known to be reversible with otherwise no known long-term complications, NAFLD has been shown to progress to cirrhosis and cause hepatocellular carcinoma. Definite diagnosis often requires liver biopsy because of overlapping clinical and radiographical pictures. Elevation of both glucose and insulin levels in the setting of fragile DM control is thought to play a role via overstimulation of glycogen synthesis. Recommended treatment is stable “tight” glycemic control; pancreatic transplantation has resulted in sustained GH remission in two case reports. The required degree of stability and tightness of glucose control is not yet known. An increased awareness of GH is needed in an attempt to prevent delay in diagnosis, in a condition with an otherwise unknown incidence.

INTRODUCTION: Dancing eye or opsoclonus-myoclonus syndrome is a rare paraneoplastic syndrome that has been mostly associated with small cell lung cancer. It was reported in association with esophageal cancer in one case. Here we report a second case. CASE DESCRIPTION/METHODS: A 59-year-old man presented with 5 weeks of rapidly worsening vertigo and gait difficulty that lead to frequent falls and inability to perform daily activities. About 5 weeks prior to presentation, he completed three rounds of cisplatin and 5-FU for recently diagnosed squamous cell carcinoma of the esophagus. He had long standing hypertension treated with hydrochlorothiazide, lisinopril, and carvedilol, and diabetes mellitus treated with glipizide, glyxambi, and sitagliptin. He denied alcohol, tobacco, or illicit drug use and recent viral infection. He was fully alert and oriented and afebrile. He had spontaneous, involuntary, arrhythmic, conjugate, multidirectional saccades occurring in all directions of gaze without a saccadic interval and pronounced ataxia on standing associated with unsteadiness. Complete blood count and routine chemistry were unremarkable. Brain MRI with and without contrast revealed no evidence of intracranial hemorrhage, mass lesion, acute infarct or pathologic enhancement. HIV screen was negative. Hepatits C virus antibody was non-reactive. Paraneoplastic autoantibodies screening was negative. He received 5 day course of 0.4g/kg/day intravenous immunoglobulin (IVIG) and 250 mg BID methylprednisolone with marked improvement of rhythmic eye beating at rest, coordination of multidirectional eye movements, ataxia, and vertigo by day 3. He was discharged to acute rehabilitation facility on day 8. DISCUSSION: Our patient has dancing eye or opsoclonus-myoclonus syndrome that followed the diagnosis of esophageal cancer and rapidly responded to IVIG and methylprednisolone, strongly suggesting a paraneoplastic association. Interestingly and consistent with the single case previously reported of this association, paraneoplastic autoantibodies screen was negative.