Case seriesPatient: Male, 35 • Male, 82Final Diagnosis: Idiosyncratic DILI due to CiprofloxacinSymptoms: Abdominal discomfort • fever • jaundice • nauseaMedication: CiprofloxacinClinical Procedure: —Specialty: Gastroenterology and HepatologyObjective:Challenging differential diagnosisBackground:Drug-induced liver injury (DILI) can present clinically as a spectrum that includes asymptomatic elevation of transaminases, acute or chronic hepatitis, and acute liver failure. Idiosyncratic DILI is more likely to affect individuals with comorbidities, and to have a wide range of clinical presentations. Although antibiotics are associated with DILI, the fluoroquinolone, ciprofloxacin, is a rarely reported cause. Two cases of idiosyncratic DILI following ciprofloxacin treatment are described, including a review of the literature.Case Report:Case 1: A 35-year-old man was treated with ciprofloxacin for periorbital cellulitis. On the second day of ciprofloxacin treatment, he developed abdominal pain, nausea, vomiting and increased serum levels of liver transaminases, aspartate aminotransferase (AST), and alanine aminotransferase (ALT). Further investigations excluded infectious hepatitis, autoimmune disease, or structural liver disease. Exclusion of other causes of DILI and cessation of ciprofloxacin resulted in clinical improvement and normalization of liver function tests (LFTs). Case 2: An 82-year-old man was treated with ciprofloxacin for osteomyelitis. On the tenth day of ciprofloxacin treatment, he developed jaundice and abnormal LFTs, including increased AST, ALT, alkaline phosphatase (ALP), and total bilirubin. Further investigations excluded infectious hepatitis, autoimmune disease, or structural liver disease. Exclusion of other causes of DILI and cessation of ciprofloxacin resulted in clinical improvement and normalization of LFTs.Conclusions:Idiosyncratic DILI due to ciprofloxacin treatment is rare. These two cases have shown that timely diagnosis and discontinuation of ciprofloxacin can prevent the progression of DILI, reduce liver damage, and reduce mortality rates from DILI.

Eosinophilic myocarditis is a rare and frequently fatal disease that is often undiagnosed until autopsy. We report a case of eosinophilic myocarditis with an unusual initial presentation of palpitations that subsequently evolved into ventricular tachycardia storm and death within 4 days. ( Level of Difficulty: Beginner. )

Introduction: Non-Hodgkin lymphoma is classified as nodal and extranodal. Extranodal lymphoma frequently involves the stomach and is associated with H. Pylori infection. Colonic involvement, however, is rare. We present a case of MALT lymphoma that was found incidentally on colonoscopy. Case Description/Methods: A 73-year-old male with a history of diabetes presented for surveillance colonoscopy. Previous colonoscopy reports were unavailable, but the patient endorsed a history of benign polyps. Colonoscopy revealed a patchy area of inflammation and ulceration localized to the rectum and rectosigmoid colon. Biopsies demonstrated prominent lymphoid aggregates with inconclusive flow cytometry. He was referred to oncology who recommended further sampling. He underwent repeat colonoscopy 5 months later which demonstrated a 3 cm polyp in the cecum in addition to multiple segmental aphthae (uniform punctate lesions with surrounding erythema and central pallor) stretching from the distal sigmoid colon to the rectum. Pathology of the polyp demonstrated several lymphoid aggregates and rectosigmoid biopsies demonstrated prominent lymphoid aggregates that were positive for CD20, CD79a, BCL-2. Findings overall were consistent with extranodal marginal zone lymphoma. PET scan demonstrated diffuse lymphadenopathy, splenomegaly, and intense hypermetabolic activity throughout the colon. Stool studies were not obtained. The patient was recommended for chemotherapy with weekly rituximab which has been well tolerated to date. Discussion: Colorectal lymphoma is a rare occurrence, and represents less than 1% of all colorectal malignancies. Furthermore MALTomas present as primary colonic lymphomas in only 2.5% of cases. MALTomas predominate in men aged 50-70 years old and are associated with chronic immunosuppression and H. pylori infection when found in the stomach, although this does not necessarily hold true when found in the colon. Patients can present with symptoms of abdominal pain, obstruction, or GI bleeding. Endoscopic appearance of MALTomas is not well defined and can range from a single polypoid lesion to ulcerated mucosa or erosions. A combination of surgery, chemotherapy, and radiation is available for treatment of advanced disease.Primary colonic lymphoma is rare and there are only a few cases reported in the literature. Although rare, it is important to keep NHL in the differential when polypoid or ulcerated lesions are found on colonoscopy.

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Conclusion:In summary, this small study of 12 patients with BE and EV suggests that endoscopic surveillance may not be prioritized in the setting of varices. As a subset of these patients may still develop dysplasia and even adenocarcinoma, decision-making in this setting should weigh the relative risks of surveillance endoscopy and biopsies versus a more conservative approach. Two of these patients without adequate surveillance developed advanced pathology. This study highlights the importance and difficulty in providing adequate endoscopic surveillance in patients with BE and EV.