Patient: Female, 69 Final Diagnosis: Gastric Schwannoma Symptoms: Asymptomatic Medication: — Clinical Procedure: — Specialty: Gastroenterology and Hepatology Objective: Rare co-existance of disease or pathology Background: Schwannomas are benign tumors originating from any nerve with a Schwann cell sheath. It is an extremely rare tumor, accounting for 0.2% of all gastrointestinal tumors and 4% of all benign tumors of the stomach. Clinical differentiation of gastrointestinal mesenchymal tumors is challenging and confirmatory diagnosis requires biopsy. Surgical resection is the treatment of choice when tumor size is less than 30 mm or when it is located within the muscularis propria. Here, we present a case of a large (>50 mm) gastric Schwannoma that was resected using a new laparoscopic technique suitable for larger tumors. Case Report: A 69-year-old woman with past medical history of hypertension, diabetes mellitus, and stroke, and CKD stage 4, presented to the Emergency Department (ED) with persistent nausea, vomiting, and weakness. She was found to have uremia requiring emergent hemodialysis. Eventually, she underwent peritoneal catheter insertion for peritoneal dialysis. A mass on the gastric antrum was found incidentally during the procedure. Biopsy confirmed the diagnosis of gastric Schwannoma. The tumor was removed successfully using a minimally invasive procedure via robotic-assisted laparoscopy. Conclusions: Gastric Schwannoma is a rare submucosal tumor arising from Auerbach’s plexus in the muscularis propria. It is usually asymptomatic, but can present with symptoms such as epigastric pain, or upper gastrointestinal bleeding. Tissue biopsy and immunohistochemical staining are the criterion standard for diagnosis. It has no tendency for malignant transformation. Tumors smaller than 30 mm are removed endoscopically, while tumors larger than 30 mm can be removed surgically. In this case, the tumor was removed successfully by minimally invasive robotic-assisted laparoscopy.

Tolosa-Hunt syndrome is a rare condition involving the orbital and retro-orbital space. The typical symptoms are orbital pain, swelling, headache, palsies of the cranial nerves, and sensory loss in the distribution of the trigeminal nerve. Tolosa-Hunt syndrome relapses and remits with episodes separated by months to years. It is a diagnosis of exclusion after ruling out other causes of painful ophthalmoplegia and is treated with high-dose steroids. We present a case of a 43-year-old woman with a history of recurrent headaches and vision disturbances for the past 4 years presenting with worsening left-eye pain that radiated to the back of her head, swelling around the left eye, double vision, and a unilateral left-sided headache. Visual acuity was decreased in the left eye compared to the right and the patient reported left-eye pain when at extreme medial and lateral gaze. Erythrocyte sedimentation rate (ESR) was found to be elevated with all other laboratory testing within normal limits. Computed tomography (CT) scan of the orbits was unremarkable. Ophthalmology excluded other differential diagnoses and she was treated with intravenous methylprednisolone with significant improvement of symptoms. The triad of one or more episodes of unilateral orbital pain, paresis of one or more of the cranial nerves, and granulomas by magnetic resonance imaging (MRI) or biopsy is 95-100% sensitive at diagnosing the syndrome; however, our patient did not present with the "classic" triad. Initial treatment of Tolosa-Hunt is with high-dose steroids which as in our case lead to rapid and significant improvement of symptoms.

Since the beginning of coronarvirus-2019 pandemic, prevention has been the core measure to mitigate the spread of the virus. Prevention measures included universal masking, frequent hand sanitization, and social distancing are among the measures that proved to be effective. However, these measures are also known to be effective against transmission of influenza virus. We hypothesize that during the times of Covid-19 pandemic, the incidence of influenza pneumonias will also decrease. METHODS:We utilized the Jersey Shore University Medical Center Laboratory database to identify the number of influenza tests sent before and during the pandemic. We extracted the data over the last six months in 2019 to represent the pre-pandemic period and compared them to the data of the last six months in the year of 2020 to represent the during-pandemic period. In addition, we compared the rate of decrease in monthly incidences of Influenza cases between Feb-April 2020 in our hospital (when preventive measures were applied state wide in NJ) to Feb-April of 2017 in the Mid-Atalatnic District (obtained from the Healthcare Cost and Utilization Project National Inpatient Sample 2017) to better elicit the effect of preventive measures as opposed to the natural course.RESULTS: During the last six months of 2019, there was a total of 10,304 flu tests sent inpatient. Of them, 674 tests were positive (6.5%). In comparison, there was a total of 5,406 total tests of influenza A and B sent during the last six months of year 2020; among them, only 1 case was positive (0.02%). Relative risk was 0.003. By examining the Mid-atalantic district trend of monthly incidences of influenza, it appears that influenza cases in all hospitalizations decreased from 2.5% in Feburary 2017 to 1.2% in March 2017 to 0.7% in April 2017 (Monthly decrease of 40-50%); while the incidence in our hospital decreased from 9.6% in Feburary 2020 to 2.7% in March 2020 to 0.7% (Monthly decrease of 70-75%). CONCLUSIONS:The incidence of influenza virus pneumonia has decreased significantly during the time of Covid-19 pandemic, likely due to widely encouraged preventive measures.CLINICAL IMPLICATIONS: Masking, frequent hand sanitization and social distancing proved to be very effective in reducing the incidence of influenza pneumonia. Preventive measures may be adopted in patients with high risk of mortality from influenza pneumonia, even if Covid-19 pandemic resolves.