Macrophage activation syndrome (MAS) is a rare manifestation of systemic lupus erythematosus (SLE) with potentially life-threatening consequences. To the best of our knowledge, this is the first case reported in literature for a constellation of MAS, glomerulonephritis, pericarditis, and retinal vasculitis as initial presentation of SLE. Despite extensive multisystem involvement of his disease, the patient responded well to initial steroid treatment, with mycophenolate mofetil successfully added as a steroid-sparing agent. Our case highlights the importance of multispecialty collaboration in the diagnosis and management of SLE with multisystem involvement.

INTRODUCTION: Cytomegalovirus (CMV) is a common infection in immunocompromised patients including solid organ transplant patients. CMV infection of the GI tract can present in various ways. We present a case of chronic diarrhea of one-year duration associated with anemia. CASE DESCRIPTION/METHODS: A 56 year old female with a past medical history of hypertension, end stage renal disease with renal transplant in 2004 (maintained on cyclosporine, mycophenolate mofetil and prednisone) presented to the emergency room with generalized weakness of 4-days duration. The patient further endorsed significant weight loss and gradually progressive watery diarrhea that initially was postprandial and had been present for about one year. The symptoms persisted despite treatment with anti-diarrheal agents. The patient was also found to have anemia that began around a similar time as the diarrhea, and required multiple admissions for blood transfusions. She denied melena, hematochezia, fevers or chills. During prior admissions, fecal occult blood tests were negative and stool studies were unrevealing. On admission, the patient was found to have hemoglobin (Hgb) of 5.4 g/dL, acute kidney injury and metabolic acidosis. Fecal occult blood test was positive. Colonoscopy revealed diffuse pan colonic erythematous inflamed mucosa with rectal sparing and no evidence of punched-out ulcers (see Figures 1 and 2). Qualitative CMV polymerase chain reaction study was positive. Hematoxylin and Eosin stained biopsies were inconclusive for inclusion bodies. Immunohistochemical staining for CMV was positive for scattered reactive cells. CMV colitis was diagnosed. Patient was treated with oral valganciclovir leading to complete symptom resolution, improvement of anemia and weight gain. DISCUSSION: CMV colitis in immunocompromised patients typically presents with diarrhea associated with abdominal pain, fever, leukopenia and frank hematochezia. This case represents an unusual disease manifestation with an atypical timeline of disease duration, lack of aforementioned symptoms and non-characteristic endoscopic findings, making the diagnosis challenging. Furthermore, delayed CMV infection in organ transplant patients is quite unusual, as most typically, CMV infection presents shortly after initiation of immunosuppressive therapy.

Introduction: Protein losing enteropathy (PLE) can be classified into erosive, non-erosive, and increased interstitial pressure PLE. Presenting signs are often chronic non-bloody diarrhea, anasarca, abdominal pain, and weight loss. We present a complex case of a PLE presentation with a novel diagnosis. Case Description/Methods: A 30-year-old woman with a history of migraines presented with severe abdominal pain and chronic diarrhea. She was on long-term combined estrogen-progestin oral contraceptive pills (OCP) and chronic high dose non-steroidal anti-inflammatory (NSAID) medications. She was exposed to mycoplasma pneumoniae one month prior to presentation, without other infectious exposures.

INTRODUCTION: Radiofrequency catheter ablation and pulmonary vein isolation (PVI) are electrophysiologic interventions frequently performed for the management of atrial fibrillation (AF). Given the anatomic proximity of the esophagus and left atrium, the former is prone to thermal injury which can lead to peri-esophageal nerve injury, pain, dysphagia, and atrio-esophageal fistula formation. Mechanical deflection of the esophagus away from the ablation site is being used to minimize such complications. We present a case of major esophageal bleeding secondary to mechanical trauma in the setting of esophageal deviation during AF ablation. CASE DESCRIPTION/METHODS: 60 yo female with past medical history significant for obstructive sleep apnea, pulmonary hypertension, AF with multiple direct current cardioversion attempts, underwent elective PVI using an esophageal deviation stylet (EsoSure, Northeast Scientific, Waterbury, CT). After PVI, a small amount of blood was noted as a result of suction using an orogastric tube. CT chest ruled out esophageal pathology including perforation. Subsequent upper endoscopy showed small mucosal tears in middle third of esophagus and at the esophago-gastric junction (EGJ) (Figure 1). She was discharged on daily proton pump inhibitor and remained on anticoagulation. Five days later, she presented to the emergency room with complaints of weakness, fatigue, melena and non-radiating substernal sharp chest pain. Blood pressure was 64/35. Hemoglobin was 6.4 g/dL compared to 10.3 g/dL upon discharge. Shortly after arrival, the patient had an episode of large volume hematemesis. She was urgently intubated for airway protection and volume resuscitation was initiated. Emergent upper endoscopy reveled an actively bleeding superficial mucosal tear at the EGJ which was treated successfully with epinephrine injection followed by hemostatic clip placement (Figures 2 and 3). After transfusion of 3 units of packed red blood cells, repeat Hgb improved to 8.8 g/dL and remained stable. Patient was extubated, remained clinically stable and was discharged. DISCUSSION: Mechanical displacement of the esophagus away from an atrial ablation site is being used more frequently in electrophysiologic interventions, as it reduces ablation-related esophageal thermal injury. Despite newer esophageal retractors which retain less heat and are less bulky, vigilance should be practiced to avoid mechanical esophageal trauma.