Red Man syndrome (RMS) occurs with the rapid infusion of intravenous (IV) vancomycin. RMS induced by oral vancomycin has been the focus of a limited number of case reports. We present a case of a 75-year-old female admitted with severe Clostridium difficile colitis who received oral vancomycin and by the second day of therapy, she developed flushing, erythema, and pruritus involving the face, neck and upper torso. Oral vancomycin was immediately withheld, and diphenhydramine was initiated. Clinical improvement was apparent 24 hours after discontinuation of oral vancomycin. Our case adds to the published literature on this rare clinical entity that should be considered when severe colitis patients prescribed oral vancomycin, as part of the standard of care, develop the typical signs and symptoms of RMS.

Mucormycosis is a highly invasive and rapidly progressing form of fungal infection that can be fatal. The infection usually begins after oral or nasal inhalation of fungal spores and can enter the host through a disrupted mucosa or an extraction wound. The organism becomes pathogenic when the host is in an immunocompromised state. There are several clinical presentations of mucormycosis including rhinocerebral, pulmonary, cutaneous, gastrointestinal, disseminated, and miscellaneous forms. The most common clinical presentation of mucormycosis is the rhinocerebral form which has a high predilection for patients with diabetes and metabolic acidosis. An indolent disease course taking weeks to months of this infection is rare making it difficult to diagnose. Therefore, early detection and prompt treatment with surgical and antifungal therapy are very important in achieving good treatment outcomes.

INTRODUCTION: Desmoplastic small round cell tumors (DSRCT) are a rare and aggressive variant of soft-tissue sarcomas. Data suggest that occurs as a consequence of a translocation of (11;22) (p13; q12) resulting in a fusion of EWS/WT1 genes. The incidence of DSRCT is more common in young Caucasian males between the ages of 15 and 25 [6,7]. CASE DESCRIPTION/METHODS: A 26-year-old male with no past medical history complaining of shortness of breath, anorexia, unintentional weight loss of 20 pounds and increased abdominal girth associated with pain starting two months prior to presentation. Physical exam was remarkable for cachexia, mild diffuse tenderness to palpation, protuberant abdomen without a distinct mass. Initial workup showed the following abnormality; normocytic anemia with hemoglobin of 12.6, ALP 189, AST 58, ALT 73 and HIV negative. Abdominopelvic CT scan revealed a large mass measuring 20 × 10 × 10 cm in the left upper quadrant, nodular deposits in the anterior abdomen concerning for carcinomatosis and multiple liver metastases, largest measuring 10 × 8 cm (Figure 1). Mesenteric lymph node biopsy showed findings consistent with desmoplastic fibromyxoid stroma and immunohistochemically positive for AE1/AE3, EMA, vimentin, desmin, synaptophysin, and CD99 (Figures 2–3). DISCUSSION: DSRCT's are aggressive soft tissue sarcomas that are extremely rare. They predominantly involve the pelvis, retroperitoneum, and mesentery. Upon diagnosis, it is crucial to exclude desmoid tumors and Ewing sarcomas, since, these malignancies that can be confused with DSRCT. Accumulating data suggest that is more prevalent in young adults, making the diagnosis challenging at the early stages, since, it can be potentially confused with less aggressive conditions such as gastritis, dyspepsia or gastroesophageal reflux disease. Prognosis is frequently poor given a late presentation of disease; five-year survival is estimated at 15 to 30% [2]. The exact mechanism of DSRCT is not well understood, but research suggest it arises from a translocation. Some promising therapies are undergoing phase trials as surgical interventions and hyperthermic intraperitoneal chemotherapy [2]. Systemic chemotherapy with aggressive surgical resection has shown improved outcomes [6]. Nonetheless, systemic therapy tends to be very toxic, requiring frequent admissions to control potential adverse events. Further research is needed to characterize the exact pathogenesis and treatment of this uncommon malignancy.

INTRODUCTION: Iron Deficiency Anemia (IDA) occurs in 2-5% of adults and requires workup including upper esophagogastroduodenoscopy (EGD) and/or colonoscopy.1 However, in 10-41% of patients a source of bleeding is not identified,2–5 which requires investigation of the small bowel using video capsule endoscopy (VCE). This study aims to determine the long-term outcomes in patients with IDA and a pan endoscopy-negative IDA, which entails negative EGD, colonoscopy and VCE. METHODS: Medical records at the VA NY Harbor were queried for patients with IDA and having an EGD, colonoscopy, and VCE between 2005-2015. Anemia was defined as hemoglobin less than 13 g/dL in men and 12 g/dL in women; IDA was confirmed using serum ferritin less than 100 ng/mL. Exclusion criteria included underlying causes for IDA such as pre-menopausal women or history of ulcerative colitis. Biographical, laboratory and endoscopic data were obtained. Baseline hemoglobin and ferritin levels were recorded, and subsequently followed at 1, 3, and 6-year intervals. RESULTS: A total of 7,000 records were reviewed, 311 patients had EGD, colonoscopy and VCE; 67 of these patients were excluded. Of the remaining patients, 99 patients (13 females, 86 males) had a negative initial workup and were included in analysis. The mean age was 68.2 (±11.1). IDA resolved in 37 (37.4%) patients, 49 (49.5%) patients had persistent anemia, and 13 (13.1%) patients had recurrent anemia. Of the 99 patients with negative workup, 80 (80.8%) patients went on to have subsequent EGD, colonoscopy or VCE. 62 (62.6%) patients had subsequent EGD with 12 (19.4%) patients having positive findings such as gastric ulcers. 64 (64.7%) patients had subsequent colonoscopies, 7 (10.9%) of these patients had positive findings such as chronically bleeding hemorrhoids. 18 (18.2%) patients had subsequent VCEs, and 5 (27.8%) of these patients had findings such as angioectasias. CONCLUSION: Our findings are consistent with previous reports suggesting that the majority of elderly patients who have an initial negative workup for IDA tend to have favorable outcomes. 21 of 80 patients (26.25%) had some findings on subsequent workup to explain IDA, however those findings were benign. In addition to previous published data, our study highlights the significance of VCE as a tool for identifying a bleeding source. Our study also emphasizes the need for randomized control studies to determine the optimal workup strategy for patients with initially negative bidirectional endoscopy and VCE.