Bullous pemphigoid is a chronic autoimmune blistering disease. Recently, several reports suggested dipeptidyl peptidase 4 (DPP-4) inhibitors, also known as gliptins, were a potential cause of drug-induced bullous pemphigoid but not of both bullous pemphigoid and alopecia areata together. Here we describe the case of a 68-year-old man with type 2 diabetes mellitus who developed new onset diffuse alopecia on the scalp with diffuse tense bullae over his body a few months after linagliptin was introduced for better control of his diabetes. DPP-4 inhibitors are not known to increase the risk of alopecia. To the best of our knowledge, this is the first report of linagliptin-associated alopecia areata and bullous pemphigoid, which may help demonstrate if there are any links between DPP-4 inhibitors and alopecia. LEARNING POINTS • This is the first report of linagliptin-associated alopecia areata and bullous pemphigoid (BP), which may help demonstrate a link between DPP-4 inhibitors and alopecia. • Since the time of onset of BP after initiation of a DPP-4 inhibitor varies, a high index of suspicion is needed for diagnosis. • Early diagnosis is essential as DPP-4 inhibitor withdrawal has a significant effect on disease remission.

A 70-year-old male with a complex past medical history presents with confusion and slurred speech for 24 hours. His exam was unremarkable, and his CT head was negative. Both his C-reactive protein and white blood cell count were elevated. As part of the delirium workup, blood cultures were done which grew Streptococcus pyogenes with no obvious source. He was treated with appropriate antibiotics. To determine the source, a white blood cell scan was done, which showed increased localization within a left-sided upper mediastinum mass. Subsequently, chest CT scan with contrast showed an acute type B aortic dissection with mycotic aneurysm. Consequently, he was taken urgently for surgical management. He completed 6 weeks of penicillin G and was discharged to a rehabilitation center. This case illustrates both a rare entity, mycotic aneurysm secondary to Streptococcus pyogenes, and the importance of getting an Infectious Diseases consult in the setting of an unknown source of bacteremia.

Background Eosinophilic esophagitis (EoE) is a chronic, allergic/immune condition of esophagus characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. Aims Despite different drugs were studied for the treatment of EoE, there is no consensus on what the most effective medical interventions. We performed a systematic review and meta-analysis of RCTs to compare the efficacy of medical interventions in patients with EoE. Methods We searched MEDLINE, EMBASE and the Cochrane CENTRAL (via OvidSP) published from inception to November 01, 2018, to identify RCTs assessing the efficacy of medications (PPIs, steroids, anti-IL5 agents, anti-IL13 agents, anti-IL-4Rα agents and mast cell stabilizers) in patients with EoE. Outcomes were symptoms improvement and histology improvement. Studies that only reported continuous scores were excluded. Pooled risk ratios (RR) with 95% confidence intervals (CI), using a random effects model, were calculated. Results Among 1311 citations, 19 RCTs (n=1239 EoE cases) were included. 11 RCTs compared steroids vs placebo, two compared PPIs vs steroids, two compared anti- IL-13 vs placebo, two compared anti-IL-5 vs placebo, one compared anti-IL-4Rα vs placebo, and one compared mast cell stabilizer vs placebo. Steroids demonstrated significant improved in histology (63.3% vs 2.9%; RR 10.12, 95% CI 4.56–22.46) and improved EOE symptoms (39.6% vs 20.0%; RR =1.91, 1.16,3.14) compared to placebo. No difference was seen between oral and inhale steroids. No significant difference was seen between PPI vs prednisone either in symptom (RR 1.33, 0.36, 4.97) or in histology improvement (RR 1.83,0.76,4.40). Limited data suggest there is no significant difference between anti-IL-13 vs placebo; and anti-IL5 vs placebo; anti-IL-4Rα dupilumab but not mast cell stabilizer cromolyn may significantly improve histology compared to placebo. No substantial heterogeneity was seen in all analyses. Conclusions Current evidence suggests steroids significantly improve histology as well as symptoms in patients with EoE in compared to placebo. There is no significant difference between steroids and PPI. Data relate to other newer agents are limited. This meta-analysis highlights the variability in the interventions of EoE and the need for further studies to determine the optimal intervention. Funding Agencies None

Background Vancomycin is the recommended first-line therapy for mild to severe Clostridioides difficile infection (CDI). However, oral vancomycin is associated with disruption of the indigenous microbiota, predisposing patients to overgrowth of endogenous pathogens such as vancomycin-resistant enterococci. Aims The primary objective of the study is to examine the effect of the treatment regimens of CDI on the risk of infection with gram-negative organisms in adult patients treated for CDI. Methods A retrospective cohort study of 319 adult patients treated for CDI at Hamilton Health Sciences in the year 2015. A multivariate logistic regression analysis was performed to determine if oral vancomycin-based therapy is associated with an increased risk of infection with gram-negative organisms after adjustment for other factors. Results Eighty-one patients were excluded because of recurrent episodes of CDI within the same year or missing information. 238 patients were included in the final analysis. 48 (20.2%) patients had positive culture for gram-negative organisms after onset of CDI. Urine was the most common source for gram-negative organisms (39/48, 81.3%) followed by blood (8/48,16.7%). The most common isolated gram-negative organisms were Escherichia coli (18/48, 37.5%) and Klebsiella pneumonia (9/48, 18.8%). The most common CDI treatment regimens were metronidazole monotherapy (137/238, 57.6%), vancomycin monotherapy (13/238, 5.5%), and combination therapy (88/238, 37.0%). Among patients who were treated with metronidazole monotherapy, vancomycin monotherapy, and combination therapy, 30(30/137, 21.9%), 3 (3/13,23.1%), and 15 (15/88, 17.1%) had positive culture for gram-negative organisms, respectively (P= 0.6). Ninety-seven (97/238,40.8%) patients had severe CDI, 40 (40/97, 41.2%) were treated with metronidazole monotherapy, 5(5/97, 5.2%) with vancomycin monotherapy, and 52 (52/97, 53.6%) with combination therapy. 26 (26/141,18.4%) and 22 (22/97, 22.7%) had positive culture for gram-negative organisms among patients with non-severe and severe CDI, receptively (P= 0.7). In the multivariate analysis, neither type of CDI treatment regimen (P=0.2, 95% CI 0.30–1.31) nor CDI severity (P=0.4, 95% CI 0.67–2.69) was associated an increased risk of infection with gram-negative organisms after CDI onset. Conclusions Contrary to the reported literature, we did not find that oral vancomycin-based CDI treatment was associated with increased risk of infection with gram-negative organisms. Funding Agencies None

Background: Vancomycin is associated with disruption of the indigenous microbiota, potentially predisposing patients to overgrowth of endogenous pathogens. Our objective was to determine whether high-dose oral vancomycin is associated with cultures growing gram-negative organisms in adult patients with Clostridioides difficile infection (CDI).Methods: This is a retrospective cohort study of 632 adult patients with CDI from January 2015 to December 2017. The primary outcome was prevalence of cultures growing gram-negative organisms within 6 months after onset of the first episode of CDI. A multivariate logistic regression analysis was used to determine predictors of the outcome.Results: One hundred fifty-three patients (24.2%) had cultures growing gram-negative organisms after onset of CDI, where urine (97, 63.4%) and blood (27, 17.7%) were the most common sources. The most commonly isolated gram-negative organisms were Escherichia coli (49, 32.0%) and Klebsiella species (34, 22.2%). A total of 38 (38/100, 38.0%) and 48 (48/199, 24.1%) of the patients who received high-and standard-dose oral vancomycin, respectively, had gram-negative organism growth on culture (odds ratio [OR], 2.22, 95% confidence interval [CI], 1.41-3.5; P = 0.02). The multivariate analysis showed that high-dose oral vancomycin (OR, 2.21; 95% CI, 1.29-3.79; P = 0.004) and recent use of antibiotic therapy within 3 months (OR, 2.11; 95% CI, 1.27-3.52; P = 0.004) were associated with positive cultures growing gram-negative organisms.Conclusions: High-dose oral vancomycin therapy for CDI was associated with increased risk of gram-negative organisms probably throughout disruption of the indigenous microbiota.