Clinical Case Summary

Background: Bacterial infections are frequent complications in liver cirrhosis and major contributors to mortality. Infectious endocarditis (IE) is rare but often overlooked due to non-specific manifestations like fever, encephalopathy, or general deterioration.
Materials and methods: We report the case of a 54-year-old man with decompensated alcoholic cirrhosis, admitted in March 2024 to the Institute of Gastroenterology and Hepatology, Saint Spiridon Emergency Hospital Iași, for asthenia, jaundice, and anorexia. Upon admission, clinical examination, laboratory tests, blood cultures, urinalysis, abdominal ultrasound, chest X-ray, and oesophagogastroduodenoscopy (EGD) were performed.
Results: Initial labs showed anemia, thrombocytopenia, coagulopathy, systemic inflammation, hyponatremia, metabolic acidosis, liver dysfunction, and elevated bilirubin. Abdominal ultrasound revealed hepatomegaly and splenomegaly, without ascites. EGD showed medium esophageal varices. On day three, fever and Streptococcus gallolyticus bacteremia prompted echocardiography, which revealed aortic valve vegetations and severe regurgitation. Antibiotics (amoxicillin, clindamycin → gentamicin) were started. Clinical status worsened with suspected acute pancreatitis, progressing hepatocytolysis, cholestasis, cardiocirculatory failure, and severe electrolyte imbalance, requiring ICU transfer, intubation, vasopressors, transfusions, and broad-spectrum antibiotics. Tracheal aspirate and blood cultures later identified Acinetobacter baumannii; repeat echocardiography confirmed new vegetations. Despite maximal support, the patient developed irreversible multiorgan failure and died one month post-admission.
Conclusions: Although bacteremia is common in cirrhosis, infectious endocarditis remains underdiagnosed. Chronic liver disease contributes to poor prognosis and rapid deterioration in patients with IE.

References

Ioannou P, Savva E, Kofteridis DP. Infective endocarditis in patients with liver cirrhosis: a systematic review. J Chemother. 2021 Nov;33(7):443-451. doi: 10.1080/1120009X.2021.1878332. Epub 2021 Jan 29
Yallowitz AW, Decker LC. Infectious Endocarditis. 2023 Apr 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan

Clinical Case Summary

Hydatid cyst disease, caused by the Echinococcus parasite, is a zoonotic infection that typically targets the liver, lungs, and nervous system. It commonly occurs in regions such as the Maghreb countries, where it presents a significant health concern. While hydatid cysts in the liver are usually asymptomatic, complications such as cyst rupture, infection, or obstruction can arise, with portal vein involvement being particularly rare. This case report describes a 56-year-old male with a history of surgery for hydatid liver cyst, who presented with portal vein invasion mimicking portal vein thrombosis. Diagnostic imaging, including Color Doppler ultrasound and MRI, revealed a multiloculated cyst in the fourth liver segment with communication to the portal vein, leading to thrombosis and cavernous transformation of the portal vein. Despite the rupture of the hydatid cyst into the portal vein, no anaphylactic shock occurred. Portal vein thrombosis and cavernous transformation due to hydatid cysts represent an exceptional and complex complication of echinococcosis, highlighting the importance of early recognition and appropriate management. Treatment strategies should address both the hydatid liver cyst and associated portal hypertension, with surgical intervention being the cornerstone, including hepatectomies and laparoscopic approaches. This case highlights the necessity of heightened clinical awareness in endemic regions for managing this rare, potentially life-threatening complication.

Introduction

Gastric peroral endoscopic myotomy (G-POEM) is an emerging endoscopic technique for the treatment of refractory gastroparesis, particularly benefiting patients with pylorospasm. It is considered a safe procedure with a low risk of adverse events when performed by experienced endoscopists. Our aim was to perform a comprehensive analysis of all adverse events associated with G-POEM.

Aims & Methods

We performed a retrospective analysis of prospectively collected data from all patients who underwent G-POEM for gastroparesis at our centers (Prague, Brno) between November 2017 and April 2025. All procedures were performed by a single endoscopist (JM). The primary outcome was procedure-related adverse events rate and severity occurring during the perioperative and early postoperative period. Adverse events were categorized as follows: deviations from the expected peri and postoperative course were defined as "undesirable events." Undesirable events that met the criteria of the Clavien Dindo surgical classification (C-D) were considered "true adverse events".

Results

Out of 70 procedures, no true adverse or undesirable events occurred in 51 procedures (72.9%). Perioperatively, the following undesirable events occurred in 18 patients: : gastric (4; 5.7%) and duodenal mucosal injuries (2; 2.8%), major bleeding during the procedure treated endoscopically (1; 1.4%), serosal perforation (10; 14.3%), capnoperitoneum requiring puncture (3; 4.3%), and subcutaneous emphysema (1; 1.4%). In the early postoperative period, adverse events occurred in 3 patients: one patient complained of significant abdominal pain necessitating analgetics, subsequently, a small leak from the pyloric region to the subhepatic region was described on CT and gastroscopy confirmed ulceration at the tunnel site. The patient responded well to treatment with intravenous proton pump inhibitors. In two other cases, both involving patients with diabetic gastroparesis, decompensation of diabetes occurred during the hospital stay post-procedure. The following “undesirable” events were considered true adverse events according to the C-D classification: serosal perforation (10; C-D I), leak requiring prolonged hospitalization (1; C-D IIIa) and diabetes decompensation (2; C-D II). These complications occurred in 13 procedures (18.6%).
The mean duration of hospitalization after the procedure was 2 days (range 1-7). Three months after the procedure, 1 patient developed mild dumping syndrome, which was successfully treated conservatively.

Conclusion

G-POEM is a safe procedure. The rate of true adverse events according to Clavien-Dindo classification is low and severe AEs occurs rarely.

Clinical Case Summary

Cryptosporidiosis is a gastrointestinal infection caused by the protozoan Cryptosporidium spp. It is typically self-limited in immunocompetent patients. However, in immunocompromised individuals, it can lead to moderate to severe diarrhea and significant morbidity and mortality.¹
We present the case of a 31-year-old woman with a history of Crohn’s disease in remission, who presented with a one-week history of diarrhea (up to 10 bowel movements daily), abdominal pain, and fever (38°C). Laboratory tests revealed an elevated C-reactive protein (CRP), and intestinal ultrasound showed bowel wall thickening, hyperemia and wall disruption, suggestive of an active flare. However, routine stool culture isolated Cryptosporidium, and based on her clinical background, oral paromomycin and azithromycin were initiated, resulting in complete clinical remission.
Cryptosporidiosis is a common parasitic cause of diarrhea, particularly affecting immunocompromised patients, such as those with HIV, cancer or solid organ transplants.²
Although few cases have been described in inflammatory bowel disease (IBD), the immunosuppressive state of these patients may increase the risk of infection. Diagnosing cryptosporidiosis in this population can be challenging, as stool tests detect only about 30% of cases, and the clinical presentation often mimics an IBD flare.³
Treatment is generally supportive and reserved for severe or refractory cases. Nitazoxanide is the drug of choice, and in non-responders, it can be combined with fluoroquinolones or azithromycin. In IBD patients, the decision to initiate specific antiparasitic treatment depends on the degree of immunosuppression and the clinical scenario.⁴
A clear association between IBD and cryptosporidiosis has not been established, but it is crucial to rule out opportunistic gastrointestinal infections in suspected flare-ups before starting specific therapies.
image "Bowel wall thickening, hyperemia, and disruption of the normal layer pattern."

References

(1) Janssen B, Snowden J. Cryptosporidiosis. 2023 Jul 10. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 28846353.
(2) Liu B, Schnider A, DeArmond M, Banach DB, Haubrich BA. Cryptosporidiosis in individuals with inflammatory bowel disease: a scoping review protocol. BMJ Open. 2024 Oct 15;14(10):e086529. doi: 10.1136/bmjopen-2024-086529. PMID: 39414295; PMCID: PMC11481120.
(3) Ferreira J, Baden R, Magge S, Cheifetz A. Cryptosporidiosis masquerading as a Crohn's flare. Inflamm Bowel Dis. 2011 Oct;17(10):E133-4. doi: 10.1002/ibd.21811. Epub 2011 Jul 7. PMID: 21739536.
(4) Manthey MW, Ross AB, Soergel KH. Cryptosporidiosis and inflammatory bowel disease. Dig Dis Sci 1997;42:1580–6.

Clinical Case Summary

Introduction: Wilson’s disease is a rare inherited liver disorder caused by copper metabolism dysfunction,whereas Crohn’s disease is a chronic inflammatory bowel condition.The co-occurrence of both conditions in an adolescent is extremely rare and becomes particularly noteworthy when associated with severe complications.
Case presentation: We report a 17-year-old male with cirrhotic Wilson’s disease,stable on D-penicillamine, who developed severe anal pain and bloody diarrhea.On proctologic examination,he had hemorrhoids, a s crotal fissure,and a non-draining anal fistula.
Laboratory investigations revealed severe anemia (Hb 4.4 g/dL),leukopenia,and elevated C-reactive protein. Colonoscopy showed multiple ileocolic ulcers on edematous mucosa, suggestive of active Crohn’s disease, confirmed by histopathological examination of biopsies. Pelvic MRI identified a grade II active, intersphincteric, abscessed perianal fistula. Antibiotic therapy was initiated accordingly. The patient was treated with high-dose intravenous corticosteroids for three weeks, followed by oral tapering, leading to significant clinical and laboratory improvement. However, during hospitalization, he developed disseminated intravascular coagulation (DIC) with thrombotic microangiopathy, requiring transfusion of fresh frozen plasma.His condition improved favorably thereafter
Discussion: The coexistence of Wilson’s and Crohn’s diseases is extremely rare. This case stands out for the onset of severe Crohn’s in a patient with chronic liver disease, a complex perianal fistula needing multidisciplinary care,and DIC with thrombotic microangiopathy—likely from systemic inflammation. It highlights the diagnostic and therapeutic challenges in adolescents with multiple chronic illnesses

Conclusion: The association between Wilson’s disease and Crohn’s disease is exceedingly rare. This case emphasizes the need for a multidisciplinary approach in managing complex patients, particularly when faced with severe complications.

Clinical Case Summary

A 72-year-old patient with a history of atrial fibrillation on treatment and cirrhosis, presented with subjective fevers and abdominal distention for 2 months. An initial laboratory work-up showed an inflammatory syndrome and a prothrombin level of 40 %. The rest of the work-up was unremarkable. A computed tomography (CT) scan of the abdomen showed dysmorphic liver with signs of portal hypertension and abundant ascites with micronodular infiltration of the greater omentum.
Paracentesis showed ascitic fluid (AF) with total nucleated cells 2400 with 5% neutrophils and 87% lymphocytes and protein levels at 40. Cytology was negative for malignancy.
Initially, the patient was considered for diagnostic laparoscopy to investigate the persistent abdominal symptoms. However, in light of the current epidemiological context, marked by a heightened incidence of tuberculosis in the region, a systematic workup for tuberculosis was prioritized. Direct examination and culture for acid-fast bacilli (AFB) were negative, however Xpert Mtb/Rif was positive. standard chest X-ray showed a normal parenchyma with a small right pleural effusions. Thoracentesis was done and pleural fluid AFB culture was negative.
He was started on isoniazid, rifampin, pyrazinamide and ethambutol and was discharged with a close follow up.