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Halloran, Sean

The University of Toledo Translation Journal of Medical Sciences 
Gastroenterology Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e1 
Discovery of Gastric Adenocarcinoma 
during PEG Tube Placement in Patient 
with Epiglottic Squamous Cell Carcinoma 
SJ Halloran, M31*, S Stanley, DO1, J Burlen, MD1, M Aziz, MD1, B Hart, MD, PhD, 
MPH1
1Division of Gastroenterology and Hepatology, Department of Medicine, The 
University of Toledo, Toledo, OH 43614 
*Corresponding author: sean.halloran@rockets.utoledo.edu
Published: 05 May 2023 
Introduction:  Multiple primary neoplasms constitute up to 2-17% of cancer diagnoses. We report a 
patient who was diagnosed with gastric adenocarcinoma at the time of percutaneous endoscopic 
gastrostomy (PEG) tube placement for dysphagia secondary to squamous cell carcinoma of the anterior 
epiglottis.     
Case Description:  A 77-year old male presented for upper endoscopy with PEG tube placement. Two 
months prior, the patient was diagnosed with p16 negative invasive squamous cell carcinoma of the 
anterior epiglottis. He was referred for PEG tube placement for nutrition supplementation due to 5 
months of progressive dysphagia, malnutrition, and unintentional weight loss. Social history was 
significant for tobacco dependence with 52 pack years and alcohol dependence. At the time of PEG tube 
placement, a 1.5 cm excavated lesion at the gastric incisura was identified. Biopsy was performed to rule 
out malignancy. PEG tube was successfully placed. Biopsy was consistent with diffuse type signet ring 
gastric adenocarcinoma. PET scan 1 month prior to PEG tube placement showed no foci of abnormal 
FDG uptake outside of the primary lesion in the epiglottis. Patient is undergoing treatment for laryngeal 
carcinoma with chemotherapy and radiation. Assessment and treatment for gastric cancer diagnosis will 
be deferred until completion of treatment for laryngeal carcinoma.    
Discussion:  Concurrent laryngeal and gastric cancer is a unique diagnosis not well reported. Literature 
shows that signet ring cell carcinomas has significantly lower 18F-FDG uptake than other forms of 
gastric cancer. These findings highlight the importance of completing a full endoscopic evaluation in all 
patients undergoing endoscopy. 
https://dx.doi.org/10.46570/utjms.vol11-2023-672 


English

Discovery of Gastric Adenocarcinoma during PEG Tube Placement in Patient with Epiglottic Squamous Cell Carcinoma

Kloster, Alex

The University of Toledo Translation Journal of Medical Sciences 
Internal Medicine Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e1 
Heerfordt-Waldenstrom Syndrome: A Case Report 
Alex Kloster1*, Ziad Abuhelwa1, Adam Meisler2, Barat Venkataramany1, Ragheb 
Assaly3
1Division of Internal Medicine, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
2Department of Neurology, The University of Toledo, Toledo, OH 43614 
3Division of Pulmonary and Critical Care Medicine, Department of Medicine, The 
University of Toledo, Toledo, OH 43614 
*Corresponding author: Alex.Kloster@utoledo.edu
Published: 05 May 2023 
Background: Heerfordt-Waldenstrom Syndrome(HWS) is a variant of sarcoidosis, which presents with 
swelling of the Parotid or salivary glands, facial nerve paralysis and anterior uveitis. The incidence is 
rare, with only 6% of sarcoidosis patients having parotid gland enlargement, and 5% of patients with 
cranial nerve palsy.   
Case Presentation: A 44-year-old woman with non-significant past medical history presented to the 
emergency department with several weeks of low back and flank pain. She was also complaining of 
weakness, weight loss, voice hoarseness and worsening shortness of breath. Six months prior to her 
presentation, she was diagnosed with a left sided facial nerve palsy. Examination revealed bilateral 
parotid gland enlargement, left ptosis, left facial drooping and cervical, axillary and femoral 
lymphadenopathy. Workup for malignancy was negative. Tests for syphilis, acid-fast bacilli and fungal 
infection were negative. ACE levels found to be increased. CT neck and chest revealed extensive 
lymphadenopathy, multiple lung nodules and infiltrative densities replacing bilateral parotid glands. 
Lymph node biopsy confirmed revealed necrotizing granulomas, confirming diagnosis. Patient was 
initiated on Solumedrol 125mg bid, after which she endorsed improvement in voice hoarseness, 
shortness of breath and pain. She was transitioned to prednisone 60mg daily and azathioprine 50mg 
daily at discharge and will follow up with rheumatology and pulmonology for further management.  
Discussion/Conclusion: Heerfordt-Waldenstrom syndrome should be considered in the differential for 
new onset facial nerve palsy without a clear source. When only two of the symptoms are present, it is 
considered incomplete HWS. 
https://dx.doi.org/10.46570/utjms.vol11-2023-708 


Heerfordt-Waldenstrom Syndrome: : A Case Report

Chen, Bohan

The University of Toledo Translation Journal of Medical Sciences 
Nephrology Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e1 
MC1R Deficiency Enhances Th1 Response 
and Impairs Regulatory T Cell Homeostasis 
In Nephrotoxic Serum Nephritis 
Bohan Chen1*, Xuejing Guan1, Yan Ge1, Lance Dworkin1, Rujun Gong1 
1Division of Nephrology, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
*Corresponding author: Lance.dworkin@utoledo.edu
Published: 05 May 2023 
Background: The melanocortin neuropeptides, represented by adrenocorticotropic hormone, have 
recently emerged as a novel therapeutic choice for treating refractory glomerular diseases. As a key 
cognate receptor of the melanocortin hormone system, melanocortin 1 receptor (MC1R) plays a pivotal 
role in regulating immune response and inflammation, and has become a novel therapeutic target for a 
number of diseases. However, its role in the pathogenesis of immune-mediated glomerular disease 
remains unknown.   
Methods: Wild-type (WT) mice and the recessive yellow mice (e/e) with the naturally occurring loss-of-
function null mutation of MC1R received injection of the rabbit anti-mouse nephrotoxic serum (NTS) to 
develop the NTS nephritis and were examined 2 weeks later.   
Results: The e/e mice developed more severe crescentic glomerulonephritis than WT mice, marked by 
aggravated proteinuria, kidney dysfunction, and renal lesions like glomerular hypercellularity, crescent 
formation, and renal inflammation and fibrosis. The exacerbated NTS nephritis in e/e mice was 
associated with greater levels of autologous IgG2c and IgG3 either deposited in glomeruli or in sera. In 
addition, profiling of signature cytokines of Th immunity revealed that e/e mice with NTS nephritis 
exhibited higher renal expression of IFN-γ, and an increasing trend in renal expression of TNF-α, as 
compared with WT mice, consistent with a reinforced Th1 immune response. Moreover, shown by 
immunohistochemistry staining, the number of FoxP3+ regulatory T cells in the NTS nephritic kidneys 
was diminished in e/e mice, as compared with WT mice. Mechanistically, MC1R was evidently detected 
in diverse renal leukocytes prepared from the diseased WT mice, including T lymphocytes, suggesting 
that T cells may be direct effector cells of the melanocortin hormones via MC1R signaling.    
Conclusion: MC1R-mediated melanocortinergic signaling represses Th1 immune response and is 
required for regulatory T cell homeostasis in murine models of NTS nephritis, resulting in renal 
protection in experimental crescentic glomerulonephritis. 
https://dx.doi.org/10.46570/utjms.vol11-2023-763 


MC1R Deficiency Enhances Th1 Response and Impairs Regulatory T Cell Homeostasis In Nephrotoxic Serum Nephritis

Faleel, Dhilhani

The University of Toledo Translation Journal of Medical Sciences 
Nephrology Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e1 
Computational and Experimental Analysis 
Reveals the Arachidonic Acid Metabolite 
20-Hydroxyeicosatetraenoic Acid is a Novel
Ligand of the Na/K-ATPase
Dhilhani Faleel1*, Shungang Zhang1, Jacob A. Connolly1, Deepak Malhotra1, Steven T. Haller2, John R. Falck1, 
David J. Kennedy2 
1Division of Nephrology, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
2Division of Cardiovascular Medicine, Department of Medicine, The University of 
Toledo, Toledo, OH 43614 
*Corresponding author: Dhilhani.Faleel@rockets.utoledo.edu
Published: 05 May 2023 
Objective: We sought to determine the ability of 20-HETE to bind with the NKA relative to other 
known NKA ligands using a computational molecular modeling approach. We further sought to test the 
ability of 20-HETE to stimulate NKA mediated signaling in renal proximal tubule cells.  
Methods: Computational molecular modeling to investigate the interaction of 20-HETE and NKA was 
performed using Maestro software analysis (Schrodinger 2021-2).  In vitro experiments of NKA 
signaling were performed with both 20-HETE and its stable analog, 5,14-20-HEDE, in renal LLC-PK1 
proximal tubule cells. 
Results: First, we performed induced fit docking to predict the binding free energy of both 20-HETE 
and its stable analog, 5,14-20-HEDE, in comparison with the well-established cardiotonic steroid NKA 
ligand telocinobufagin. This docking analysis predicted that 20-HETE and 5,14-20-HEDE interact with 
the NKA with similar binding free energy as cardiotonic steroids (Predicted binding free energies: 
telocinobufagin =-9.2; 20-HETE= -8.5 and 5,14-20-HEDE = -8.18). Further this computational 
modeling demonstrated that all of these molecules interact in the same binding pockets of the NKA. 
Next, our in-vitro experiments showed that 20-HETE and its analog 5,14-20-HEDE increased MAPK 
activation in a dose dependent manner from 10 nM to 10 uM in LLC-PK1 cell lines. This MAPK 
activation was significantly reduced after pretreatment with pNaKtide, a specific inhibitor of the NKA-
Src signaling complex (1uM pNaKtide, 30 minutes).   
Conclusion: The result of these study suggests that 20-HETE interacts with NKA in similar manner as 
cardiotonic steroids and is capable of inducing NKA signaling in renal proximal tubules. 
https://dx.doi.org/10.46570/utjms.vol11-2023-767 


Computational and Experimental Analysis Reveals the Arachidonic Acid Metabolite 20-Hydroxyeicosatetraenoic Acid is a Novel Ligand of the Na/K-ATPase

Please view the PDF to see the formatted meeting abstract

Dworkin, Lance D.

The University of Toledo Translation Journal of Medical Sciences 
2022 Department of Medicine Research Symposium  UTJMS 2023 May 5; 11(1):e1-e1 
https://dx.doi.org/10.46570/utjms.vol11-2023-791 
Editorial 
Lance D. Dworkin, MD1* 
1Guest Editor, Division of Nephrology, Department of Medicine, The University of 
Toledo, Toledo, OH 43614 
*Corresponding author: Lance.Dworkin@utoledo.edu
Published: 05 May 2023 
This edition of Translation contains the abstracts submitted to the Third Annual installment Annual 
Research Symposium of the Department of Medicine, University of Toledo College of Medicine & Life 
Sciences.  I wish to thank the editors and staff of the Journal for making this edition possible.  It is the 
first time the abstracts of that meeting are being formally published and we greatly appreciate the 
opportunity.   
The Annual Research Symposium serves multiple important purposes for our department and the 
College.  First, it calls attention to the depth and breadth of biomedical investigation, basic laboratory 
science, clinical translational, and quality and outcomes research that exists, but can be overshadowed 
by our clinical and educational missions.  The research programs involve people at every level, 
including faculty, staff, post-doctoral fellows, clinical fellows, graduate students, residents, medical and 
undergraduate students, all working collaboratively on diverse projects in each of our 11 divisions.  This 
year, approximately 140 abstracts were submitted to the symposium, the great majority of which have 
trainees as first or presenting authors.  
Each year as part of the symposium, we invite in a world class scientist to provide a keynote address.  
Bringing outstanding investigators on campus helps to energize us and to remind us what can be 
accomplished through science to better understand our world and to advance medical therapeutics.  The 
opportunities I had as a trainee to listen and interact with leading investigators who came on campus are 
still some of my favorite memories from my entire academic career.  
Publishing the abstracts is also a critical component of the program.  Even in a single department like 
Medicine, individual research efforts can become siloed and investigators with overlapping interests 
may be unaware of each other’s work.  The published abstracts serve as a resource and database that 
investigators can access throughout the year to be better informed about ongoing work close to home 
and to identify potential collaborators.   
On a personal level, I am extremely proud of our trainees, faculty, and staff for their commitment to 
scholarship and to the active exchange of ideas demonstrated here.  These are fundamental values for 
any academic department, and that I believe are clearly on display in these published proceedings.  
Lance D. Dworkin, MD 
Mercy Professor of Education & Chair 
Department of Medicine 


Editorial

Madhavaram, Anvitha

Altorok, Nezam

The University of Toledo Translation Journal of Medical Sciences 
Nephrology Abstract, 
Dr. Lance D. Dworkin Department of Medicine Research Symposium 
UTJMS 2023 December 14; 11(3):e1-e2 
https://dx.doi.org/10.46570/utjms.vol11-2023-849  1  ©2023 UTJMS 
Rituximab in Kidney-Limited Microscopic 
Polyangiitis: A Case Report 
Madhavaram, Anvitha R.1*, Nezam, Altorok MD2 
1College of Medicine and Life Sciences, The University of Toledo, Toledo, OH 
43614 
2Division of Rheumatology, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
*Corresponding author: Anvitha.Madhavaram@rockets.utoledo.edu
Keywords: Microscopic Polyangiitis, Rituximab 
Published: 14 December 2023 
Background: Microscopic polyangiitis (MPA) is an immune complex mediated necrotizing vasculitis. 
The diagnosis is based on symptoms, including rapidly progressive glomerulonephritis, peripheral nerve 
disorder, lung abnormalities, and positive MPO-ANCA findings (1). The pathophysiology involves 
formation of neutrophil extracellular traps in the kidneys, which correlate with ANCA affinity for MPO 
and disease activity (2). Rituximab has been used in cases where conventional cyclophosphamide 
therapy may not be suitable (3). 
Case Presentation: A 78-year-old white male with a past medical history of gout and type 2 diabetes 
mellitus, presented with general weakness. Laboratory testing revealed serum creatinine of 5.2 mg/dl 
(normal <1.3 mg/dl) on presentation. He underwent kidney biopsy which demonstrated crescentic pauci-
immune glomerulonephritis. He was treated with two doses of rituximab 1 gram, two weeks apart every 
6 months for the past year. Upon presentation, he underwent dialysis for 2 months. After two years of 
treatment, laboratory evaluations reveal a stable creatinine of 1.77 and MPO antibody titers persistently 
elevated above 8. The patient responds well to Rituximab treatment, with stable renal function and no 
signs of extrarenal organ involvement. The plan is to continue treatment for a minimum of five years due 
to his consistently elevated MPO titer.    
Discussion: Rituximab, a monoclonal antibody against CD20, is used as monotherapy for MPA to 
induce remission or alongside prednisone in severe MPA [4]. Given the patient's age, his remarkably 
kidney-limited disease, and favorable side effect profile, rituximab infusions were initiated over 
conventional chronic corticosteroids and cyclophosphamide therapy.  
This case report highlights the kidney-limited form of MPA, and aims to underscore the utility of 
rituximab as a treatment option for kidney-limited MPA. Further research is needed to understand long-
term outcomes, optimize management, and establish guidelines for management of similar cases. 
https://dx.doi.org/10.46570/utjms.vol11-2023-849 UTJMS 11(3):e1-e2 
https://dx.doi.org/10.46570/utjms.vol11-2023-849 2 ©2023 UTJMS 
1. Yoshida, M., Yamada, M., Sudo, Y., Kojima, T., Tomiyasu, T., Yoshikawa, N., Oda, T., Yamada, M.
Myeloperoxidase anti-neutrophil cytoplasmic antibody affinity is associated with the formation of
neutrophil extracellular traps in the kidney and vasculitis activity in myeloperoxidase anti-neutrophil
cytoplasmic antibody-associated microscopic polyangiitis. Nephrology, 2016. 21(6): pp. 624-629.
doi:10.1111/nep.12736
2. Tamei, N., Sugiura, H., Takei, T., Itabashi, M., Uchida, K., Nitta, K. Ruptured arterial aneurysm of
the kidney in a patient with microscopic polyangiitis. Intern Med, 2008. 47(6): pp. 521-526.
doi:10.2169/internalmedicine.47.0624
3. Moiseev, S., Bossuyt, X., Arimura, Y., Blockmans, D., Cxernok, E., Damoiseaux, J., Emmi, G.,
Flores-Suarez, L.F., Hellmich, B., Jayne, D., Jennette, J.C., Little, M.A., Mohammad, A.J., Moosig, F.,
Novikov, P., Pagnoux, C., Radice, A., Sada, K.-E., Segelmark, M., Shoenfeld, Y., Sinico, R.A., Specks,
U., Terrier, B., Tzioufas, A.G., Vaglio, A., Zhao, M.-H., Tervaert, J.W.C., European Study Group.
International Consensus on ANCA Testing in Eosinophilic Granulomatosis with Polyangiitis. Am J
Respir Crit Care Med, 2020. 202(5): p. 1628SO. doi:10.1164/rccm.202005-1628SO
4. Allena N, Patel J, Nader G, Patel, M., Medvedovsky, B. A Rare Case of SARS-CoV-2-Induced
Microscopic Polyangiitis. Cureus, 2021. 13(5): p. e15259. doi:10.7759/cureus.15259
References 


Rituximab in Kidney-Limited Microscopic Polyangiitis: A Case Report

Holtzapple, Zachary

Al Azzawi, Mohammad

Al-Ataby, Harith

Patel, Rayna

Salih, Ayman

Abrahamian, Andrew

Safi, Fadi

The University of Toledo Translation Journal of Medical Sciences 
Nephrology Abstract, 
Dr. Lance D. Dworkin Department of Medicine Research Symposium 
UTJMS 2023 December 14; 11(3):e1-e1 
https://dx.doi.org/10.46570/utjms.vol11-2023-851  1  ©2023 UTJMS 
Prolonged Diabetic Ketoacidosis with Hyperammoniemia 
in the setting of Normal Liver Function 
Zachary Holtzapple, MD1*, Mohammad Al Azzawi, MD1, Harith Al-Ataby, MD1, 
Rayna Patel, MD1, Ayman Salih, MD1, Andrew Abrahamian, MD1, Fadi Safi, MD2
1Division of Internal Medicine, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
2Division of Pulmonology and Critical Care Medicine, Department of Medicine, The 
University of Toledo, Toledo, OH 43614 
*Corresponding author: zachary.holzapple@utoledo.edu
Published: 14  December 2023 
Background: Acute encephalopathy in the setting of diabetic ketoacidosis is typically metabolic in 
origin, but less pursued are other causes including hepatic encephalopathy, namely hyperammonemia. 
These cases are less common in the setting of diabetic ketoacidosis and more so associated with cirrhotic 
pathology, however they should not be excluded in the differential diagnosis of patients with altered 
mentation in the setting of normal liver function. 
Case Report: 37-year-old female patient presented to the emergency department with a chief complaint 
of confusion and nausea/vomiting over the past few days prior to admission.  She has past medical 
history of type 1 diabetes mellitus, and she had intermittently taken her insulin over the past year. On 
initial presentation, patient was found to be in acute respiratory distress and ill-appearing.  She was 
oriented to person but not place nor time.  
On initial lab works, the patient had severe metabolic acidosis with pH less than 7 on venous blood gas 
and bicarb of 2 with anion gap of 30 and glucose elevated 581.  Beta hydroxybutyrate was elevated on 
admission.  Patient required emergent intubation given her severe respiratory distress.  Surprisingly, her 
ammonium was elevated at 138 with normal liver function test.  
Throughout her hospital course diabetic ketoacidosis protocol was followed and patient's anion gap 
closed within the three days.  Patient was safely transitioned to subcutaneous long-acting insulin along 
with close follow-up with outpatient endocrinology. Liver function tests continue to remain stable 
throughout the hospital course. 
Conclusion: This case highlights a rare manifestation of hyperammonemia in the setting of a young 
patient with normal liver and kidney function.  It also highlights the molecular mechanisms behind 
diabetic ketoacidosis along with how they applied a clinical practice.  Often overlooked are the protein 
catabolic reactions and their bioproducts that are underlying patients with prolonged ketosis, as seen in 
this case. 


Prolonged Diabetic Ketoacidosis with Hyperammoniemia in the setting of Normal Liver Function

Khuder, PhD, Sadik

Puente, Nahshon A.

Osman, Mahasin

The University of Toledo Translation Journal of Medical Sciences 
Internal Medicine Abstract,  UTJMS 2023 December 14; 11(3):e1-e1 
Dr. Lance D. Dworkin Department of Medicine Research Symposium                
 
https://dx.doi.org/10.46570/utjms.vol11-2023-867  1 ©2023 UTJMS  
 
 
Association between autoimmune diseases 
and glioblastoma: results from national 
inpatient database 
 
Nahshon A. Puente1*, Mahasin Osman2, Sadik A. Khuder, PhD3 
 
1College of Medicine and Life Sciences, The University of Toledo, Toledo, OH 
43614 
2Division of Hematology and Oncology, Department of Medicine, The University of 
Toledo, Toledo, OH 43614 
3Division of Internal Medicine, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
 
*Corresponding author: Sadik.Khuder@utoledo.edu  
 
Published: 14 December 2023 
 
Background: Glioblastoma multiform (GBM) is the most frequent malignancy among primary brain 
tumors in adults and has one of the worst 5-year survival rates among all human cancers. Certain 
autoimmune diseases (AID) and their treatments may increase the risk of cancer.  Studies report 
conflicting data about the effects of AID on the risk of GBM. 
Objectives: To evaluate the effect of AID on the risk of GBM.   
Methods: Discharge data for 2020 Nationwide Inpatient Sample, Healthcare Cost and Utilization 
Project (HCUP), which approximates a 20% stratified sample of all US hospitalizations, were analyzed. 
Cases of AID and GBM were identified using the ICD10 codes. Autoimmune comorbidity index was 
used for the combined autoimmune diseases. Weighted Multivariable logistic regression was used to 
examine the association between GBM and AID and adjusting for sociodemographic characteristics. 
Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated using SAS survey 
logistic regression procedure. 
Results: Among 6,471,165 admissions, 178,254 patients were identified with AID. The prevalence of 
GBM in patients with AD was 0.07% compared to 0.12% in patients without AID (AOR = 0.653, CI= 
0.546-0.782, p = 0.0016). Significant reduction was found for rheumatoid arthritis (RA), lupus, and 
scleroderma. The highest reduction in the risk of GBM was for scleroderma. No significant differences 
were found for Sjogren's syndrome, psoriasis, sarcoidosis, thyroiditis, multiple sclerosis, or other AID.     
Conclusion: In the US, among hospitalized adults diagnosed with AID, patients with RA, lupus, and 
scleroderma are significantly less likely to have GBM. This reduction could be attributed to the effect of 
anti-AID drugs administered to the patients, or the nature of the activated pathways in AID that naturally 
antagonize neoplastic activation. 


Association between autoimmune diseases and glioblastoma: results from national inpatient database

Niedoba, Matthew

Chinnam, Sahithi

Sherafati, Alborz

Teletnick, Andrew

Tuttle, Natalie

Garg, Anu

The University of Toledo Translation Journal of Medical Sciences 
Rheumatology Abstract,  UTJMS 2023 December 14; 11(3):e1-e2 
Dr. Lance D. Dworkin Department of Medicine Research Symposium   
 
https://dx.doi.org/10.46570/utjms.vol11-2023-883               1                                                                              ©2023 UTJMS 
 
A Case of Bullous Systemic Lupus 
Erythematosus 
 
Matthew Niedoba1, Sahithi Chinnam1*, Alborz Sherafati2, Andrew Teletnick, Natalie 
Tuttle, and Anu Garg3 
 
1College of Medicine and Life Sciences, The University of Toledo, Toledo, OH 
43614 
2Division of Rhuematology, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
3Division of Internal Medicine, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
 
*Corresponding author: schinna@rockets.utoledo.edu  
 
Keywords: Bullous Lupus 
 
Published: 14 December 2023 
 
Introduction: Bullous systemic lupus erythematosus (BSLE) is a rare manifestation of systemic lupus 
erythematosus (SLE) with an incidence of 3.4 cases per million per year. (1) It primarily affects females, 
and adults between 20 and 40. BSLE manifests with vesicles and bullae that affect the trunk, head, neck, 
arms, legs, and mucosal membranes (2). Most lesions resolve with hyper/hypo-pigmentation without 
scarring or milia, but milia occurs in 21% of cases and scarring occurs in 16% of cases. The criteria for 
diagnosis of BSLE: 
1. Acute onset of vesicles and/or bullae on normal or erythematous skin 
2. Histopathology of subepidermal blistering with neutrophil-dominant infiltrate in superficial dermis 
3. Direct immunofluorescence of linear or granular immunoglobulin at basement membrane 
4. Elevated antinuclear antibody 
5. Exclusion of other causes (3) 
Prior diagnosis of SLE is supportive of but not required for diagnosis of BSLE since it may be the first 
manifestation of SLE. First-line treatment for BSLE is dapsone which has an efficacy of 90%. Second-
line treatment for patients unresponsive or who cannot tolerate dapsone include: glucocorticoids, 
cyclophosphamide, azathioprine, methotrexate, mycophenolate mofetil, methotrexate, and rituximab (2). 
Case Presentation: A 19-year-old female with a history of systemic lupus erythematosus, lupus 
nephritis, anemia of chronic disease, chronic impetigo, and history of septic shock secondary to 
Streptococcus pyogenes two months ago presents with bilateral lower extremity swelling with bullous 
lesions. The patient’s symptoms started one week ago and have progressively worsened. The patient 
reports her bullous lesions begin as fluid-filled blisters that leave scars when they reduce. The patient 
was on prednisone, mycophenolate mofetil, and hydroxychloroquine for systemic lupus erythematosus 
https://dx.doi.org/10.46570/utjms.vol11-2023-883 UTJMS 11(3):e1-e2    
https://dx.doi.org/10.46570/utjms.vol11-2023-883 2 ©2023 UTJMS  
 
  
 
prior to admission. The patient’s SLE has manifested with diffuse joint pain and skin rash. The patient is 
positive for antinuclear antibody, anti-chromatin IgG, anti-dsDNA, anti-RNP, and anti-Smith with low 
complement levels. Skin punch biopsies were performed on the left anterior thigh. Histopathology 
shows vacuolar interface dermatitis with subepidermal splitting with lymphocyte infiltrate in superficial 
dermis. Direct immunofluorescence was negative for IgG, IgG4, IgM, and IgA and showed 
discontinuous weak granular deposits of C3 at the basement membrane and non-specific deposits of 
fibrinogen in connective tissue. Patient was treated with dapsone, which provided significant 
improvements in skin lesions. 
Conclusion: Bullous systemic lupus erythematosus is a rare manifestation of SLE that should be 
considered as a differential diagnosis for vesiculobullous lesions in patients with SLE. BSLE must be 
differentiated from other cutaneous bullous skin lesions including bullous pemphigoid, linear IgA 
dermatosis, pemphigoid gestationis, and epidermolysis bullosa acquisita. While scarring is not a sequela 
for most cases of BSLE, it should not be considered a cause for ruling out. In this case presentation, a 
diagnosis of BSLE was made based on patient history, clinical presentation, antibodies, and 
histopathology in the setting of negative direct immunofluorescence. Criteria for diagnosis of BSLE 
should consider reassessment for patients with this presentation. 
This may be the first manifestation of SLE in patients who have not been diagnosed. 
References 
1. Bernard, P., Vaillant, L., Labeille, B., Bedane, C., Arbeille, B., Denoeux, J.P., Lorette, G., 
Bonnetblanc, J.M., Prost, C. Incidence and distribution of subepidermal autoimmune bullous skin  
diseases in three French regions. Bullous Diseases French Study Group. Arch Dermatol, Jan 1995. 
131(1): pp. 48-52. https://doi.org/10.1001/archderm.1995.01690130050009 
 
2. de Risi-Pugliese, T., Cohen Aubart, F., Haroche, J., Moguelet, P., Grootenboer-Mignot, S., Mathian, 
A.,  
Ingen-Housz-Oro, S., Hie, M., Wendremaire, N., Aucouturier, F., Lepelletier, F., Miyara, M., Bader-
Meunier, B., Rémy, P., Fabien, N., Francès, C., Barete, S., Amoura, Z. Clinical, histological, 
immunological presentations and outcomes of bullous systemic lupus erythematosus: 10 New cases and 
a literature review of 118 cases. Semin Arthriti Rheum, 2018 Aug. 48(1): pp. 83-89. Doi: 
10.1016/j.semarthrit.2017.11.003 
 
3. Odonwodo, A., Vashisht, P. Bullous Systemic Lupus Erythematosus. 2023 May 22. In: StatPearls 
[Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–.  


A Case of Bullous Systemic Lupus Erythematosus

Ahmed, Zohaib

Kelly, Andrew

Badal, Joyce

Lee-Smith, Wade M.

Gangwani, Manesh

Alastal, Yaseen

Hassan, Mona

The University of Toledo Translation Journal of Medical Sciences 
Gastroenterology Abstract
Dr. Lance D. Dworkin Department of Medicine Research Symposium 
UTJMS 2023 December 14; 11(3):e1-e2 
https://dx.doi.org/10.46570/utjms.vol11-2023-922  1  ©2023 UTJMS 
Fecal microbiota transplant is associated 
with lower risk of mortality, hepatic 
encephalopathy, ascites, and infection 
patients with severe alcohol-associated 
hepatitis: A systematic review and meta-
analysis 
Zohaib Ahmed1, Andrew Kelly1; Joyce Badal2, Wade M. Lee-Smith3, Manesh 
Gangwani1, Yaseen Alastal1, Mona Hassan1. 
1Division of Gastroenterology, Department of Medicine, The University of Toledo, 
Toledo, OH 43614 
2College of Medicine and Life Sciences, The University of Toledo, Toledo, OH 
43614 
3College of University Libraries, The University of Toledo, Toledo, OH 43614 
*Corresponding author: zohaib.ahmed@utoledo.edu
Keywords: FMT, Alcoholic Hepatitis, Alcoholism 
Published: 14 December 2023 
Introduction: Severe alcohol-associated hepatitis (SAH) is an acute, inflammatory liver disease that 
results in disruptions of the gut microbiome leading to bacterial translocation which drives systemic 
inflammation and end-organ damage. Despite high risk of mortality, treatment options are limited. Fecal 
microbiota transplant (FMT) may help restore the balance of healthy bacteria in patients with disrupted 
gut microbiomes due to SAH, which may decrease systemic inflammation, infection, and mortality. As 
the role of FMT in the treatment of SAH is not yet established, we conducted a systematic review and 
meta-analysis to evaluate the currently available literature regarding the impact of FMT on outcomes in 
patients with SAH. 
Methods: A comprehensive search strategy was used to identify studies that reported outcomes of 
patients with SAH receiving FMT compared to no FMT in Embase, MEDLINE (PubMed), Cochrane 
Library, Web of Science Core Collection, and Korean Journal Index, and Global Index Medicus. 
Outcomes of interest included 1-, 3-, and 6- month mortality, overall mortality, and risk of HE, ascites, 
upper GI bleeding, and infection. RevMan software was used for statistical analysis. 
Results: 7 studies with a total of 384 patients were included in the final meta-analysis. Patients who 
received FMT had significantly lower risk of 1-month mortality (RR: 0.51, 95% CI: 0.29-0.91, p=0.02), 
3-month mortality (RR: 0.61, 95% CI: 0.38-0.98, p=0.04), and overall mortality (RR: 0.58, 95% CI:
0.38-0.87, p=0.009) compared to those who did not receive FMT, although the difference in 6-month
mortality did not reach statistical significance (RR: 0.73, 95% CI: 0.18-2.89, p=0.65). Patients who
https://dx.doi.org/10.46570/utjms.vol11-2023-922 UTJMS 11(3):e1-e2 
https://dx.doi.org/10.46570/utjms.vol11-2023-922 2 ©2023 UTJMS 
received FMT also had significantly lower risk of hepatic encephalopathy (RR: 0.27, 95% CI: 0.16-0.46, 
p< 0.00001), ascites (RR: 0.47, 95% CI: 0.33-0.67, p< 0.0001), noncritical infections (RR: 0.36, 95% 
CI: 0.21-0.6, p=0.0001), and critical infections (RR: 0.28, 95% CI: 0.17-0.48, p< 0.00001). There was 
no significant difference in risk of upper gastrointestinal bleeding (RR: 0.77, 95% CI: 0.48- 1.24, 
p=0.28). 
Discussion: FMT for SAH is associated with significantly lower risk of 1-month, 3-month, and overall 
mortality, as well as lower risk of hepatic encephalopathy, ascites, and both critical and non-critical 
infections. Further studies, particularly large randomized controlled trials, are needed to establish the 
role of FMT in the treatment of patients with SAH. 


Fecal microbiota transplant is associated with lower risk of mortality, hepatic encephalopathy, ascites, and infection patients with severe alcohol-associated hepatitis: A systematic review and meta-analysis

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