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Tumor heterogeneity is a predominant feature of hepatocellular carcinoma (HCC) that plays a crucial role in chemoresistance and limits the efficacy of available chemo/immunotherapy regimens. Thus, a better understanding regarding the molecular determinants of tumor heterogeneity will help in developing newer strategies for effective HCC management. Chemokines, a sub-family of cytokines are one of the key molecular determinants of tumor heterogeneity in HCC and are involved in cell survival, growth, migration, and angiogenesis. Herein, we provide a panoramic insight into the role of chemokines in HCC heterogeneity at genetic, epigenetic, metabolic, immune cell composition, and tumor microenvironment levels and its impact on clinical outcomes. Interestingly, our in-silico analysis data showed that expression of chemokine receptors impacts infiltration of various immune cell populations into the liver tumor and leads to heterogeneity. Thus, it is evident that aberrant chemokines clouding impacts HCC tumor heterogeneity and understanding this phenomenon in depth could be harnessed for the development of personalized medicine strategies in future.

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BACKGROUND: Since its discovery in Wuhan, China in December of 2019, the novel coronavirus has progressed to become one of the worst pandemics seen in the last 100 years. Recently, there has been an increased interest in the hepatic manifestations of coronavirus disease 19 (COVID-19). AIM: To describe the demographic and clinical characteristics of COVID-19 positive patients and study the association between transaminitis and all-cause mortality. METHODS: This is a descriptive retrospective cohort study of 130 consecutive patients with a positive COVID PCR test admitted between March 16, 2020 to May 14, 2020 at a tertiary care University-based medical center. The Wilcoxon-rank sum test and paired t-test were used for comparing non-parametric and parametric continuous variables respectively and a multivariable logistic regression models to study the association between transaminitis and mortality using SAS version 9.4 (SAS Institute, Cary, NC, United States). RESULTS: Out of the 130 patients, 73 (56%) patients were found to have transaminitis and 57 (44%) did not. When compared to patients without transaminitis, the transaminitis group was found to have a higher median body mass index (30.2 kg/m2 vs 27.3 kg/m2, P = 0.04). In the multivariate analysis those with transaminitis were found to have 3.4 times higher odds of dying as compared to those without transaminitis adjusting for gender, the Age-adjusted Charlson Comorbidity Index and admission to the intensive care unit (P = 0.03). CONCLUSION: Our study showed that transaminitis on admission was associated with severe clinical outcomes such as admission to the intensive care unit, need for mechanical ventilation, and mortality.

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A pancreaticopleural fistula (PPF) is a rare complication of chronic pancreatitis that occurs either due to a pancreatic duct disruption or a pseudocyst extension. A pancreatic divisum, on the other hand, is a common anatomic variant of the pancreas that is rarely symptomatic. We describe a case of recurrent pleural effusion in a patient with a history of chronic pancreatitis. Investigations revealed the presence of a PPF and a concomitant complete pancreatic divisum. There was resolution of the pleural effusion on endoscopic therapy. This is the fourth reported case of a PPF in the setting of complete pancreatic divisum and the first reported case in a middle-aged female.

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Lipomas are the most common benign soft tissue tumor. Yet, strikingly simple tumors can become problematic when compounded by odd characteristics such as size and location. We report the case of a 53-year-old male who developed complete right lung collapse secondary to a large right-sided chest wall lipoma with accelerated growth in the past 6 months. Bronchoscopy revealed extrinsic compression of the right mainstem bronchus. Histopathology of the soft tissue mass was suggestive of a lipoma. The mass was not amenable to surgery due to a high risk of mortality from his underlying comorbidities. His hospital stay was complicated by progressive end-stage restrictive lung disease necessitating intubation and eventually a tracheostomy, recurrent pneumonias, multiorgan dysfunction, and his eventual demise. We highlight a rare presentation of an unchecked lipoma, which ultimately led to the death of our patient. Simple lipomas show insidious growth and can remain asymptomatic until they reach a large size. Chest wall tumors should be considered malignant until proven otherwise by excisional biopsy. This reiterates the need to treat all chest wall tumors with wide resection in order to provide the best chance for cure.

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Burkitt lymphoma is a rare, highly aggressive non-Hodgkin lymphoma with increasing incidence. Here we present a 26-year-old man with a history of a recent root canal who presented with 2 days of black, tarry stools, persistent tooth pain, and 2 weeks of fatigue, night sweats, and a 20-pound weight loss. He developed massive hematemesis while hospitalized and an esophagogastroduodenoscopy revealed innumerable, doughnut-shaped masses with central umbilication throughout the stomach, which were also the source of bleeding. Targeted biopsies revealed Burkitt lymphoma. After prompt chemotherapy treatment, repeat endoscopy showed complete resolution of all gastric masses, and the mucosa appeared normal.

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BACKGROUND: The COVID-19 epidemic has affected over 2.6 million people across 210 countries. Recent studies have shown that patients with COVID-19 experience relevant gastrointestinal (GI) symptoms. We aimed to perform a systematic review and meta-analysis on the GI symptoms of COVID-19. METHODS: A literature search was conducted via electronic databases, including PubMed, Embase, Scopus, and Google Scholar, from inception until 20 March 2020. Data were extracted from relevant studies. A systematic review of GI symptoms and a meta-analysis comparing symptoms in severe and non-severe patients was performed using RevMan V.5.3. RESULTS: Pooled data from 2477 patients with a reverse transcription-PCR-positive COVID-19 infection across 17 studies were analysed. Our study revealed that diarrhoea (7.8%) followed by nausea and/or vomiting (5.5 %) were the most common GI symptoms. We performed a meta-analysis comparing the odds of having GI symptoms in severe versus non-severe COVID-19-positive patients. 4 studies for nausea and/or vomiting, 5 studies for diarrhoea and 3 studies for abdominal pain were used for the analyses. There was no significant difference in the incidence of diarrhoea (OR=1.32, 95% CI 0.8 to 2.18, Z=1.07, p=0.28, I2=17%) or nausea and/or vomiting (OR=0.96, 95% CI 0.42 to 2.19, Z=0.10, p=0.92, I2=55%) between either group. However, there was seven times higher odds of having abdominal pain in patients with severe illness when compared with non-severe patients (OR=7.17, 95% CI 1.95 to 26.34, Z=2.97, p=0.003, I2=0%). CONCLUSION: Our study has reiterated that GI symptoms are an important clinical feature of COVID-19. Patients with severe disease are more likely to have abdominal pain as compared with patients with non-severe disease.

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Idiopathic acute eosinophilic pneumonia (AEP) is a very rare disease with fewer than 200 cases reported. It has been hypothesized to be a hypersensitivity reaction to an unidentified antigen. The clinical presentation typically involves fever, nonproductive cough, shortness of breath, and bibasilar inspiratory crackles within the first week of antigen exposure. Chest imaging usually reveals bilateral reticular and/or ground-glass opacities. Bronchoalveolar lavage demonstrates >25% eosinophils. Corticosteroids are the mainstay of treatment with good results; however, optimum dose and length of treatment are unclear. We present a case of a 31-year-old male who presented with 2 days of shortness of breath, cough, pleuritic chest pain, fevers, chills, nausea, and poor appetite in the setting of initiation of menthol-flavored cigarettes 2 weeks before presentation. He rapidly progressed to respiratory failure requiring intubation despite broad antibiotic coverage. His course was complicated by severe acute respiratory distress syndrome, circulatory shock, and renal failure. He underwent bronchoalveolar lavage testing that revealed 60% eosinophils. He was treated with steroids and was subsequently extubated and discharged. Eosinophilic counts in the blood peaked on the 10th day of admission to 34%. One week later, the patient was completely free of symptoms. The initiation of menthol cigarette use in this patient is the likely reason for ensuing acute eosinophilic pneumonia, hence adding to the sporadic reports on the role of menthol-flavored cigarettes. This case emphasizes a greater reliance on risk factors, as opposed to eosinophilic markers, for the diagnosis and treatment of acute eosinophilic pneumonia to prevent subsequent respiratory failure and intubation in such patients.

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