Volume 81 - 2018 - Fasc.3 - Letters
HPV papilloma in the lung in a Crohn's disease patient treated with Infliximab
A 74 year old male patient was admitted to the emergency room with a gastrointestinal obstruction. His medical history revealed multiple abdominal surgeries with a Hartmann's resection for perforated diverticulitis, transabdominal prostatectomy, cholecystectomy and correction of an umbilical hernia.
Giving his medical history of multiple abdominal surgeries a temptative diagnosis of gastrointestinal obstruction due to adhesions was made. Our patient underwent a laparotomy and multiple adhesions were treated with adhesiolysis. During the laparotomy a subobstructive terminal ileum was seen with a macroscopic appearance of Crohn's disease with creaping fat and active inflammation. A stricturoplasty was performed and biopsies showed the presence of granulomas. An oral treatment with budesonide 9 mg/ day, tapering with 3 mg every month, was started.
Three months later, a colonoscopy showed active terminal ileitis with ulcers. On magnetic resonance enterography there was persistent inflammation of the terminal ileum with substenosis, prestenotic dilatation of the small intestine and skip areas. At that time 6-mercaptopurine was started.
After two months 6-mercaptopurine had to be stopped due to hepatotoxicity and Infliximab was started. Due to a positive tuberculosis skin test, start of Infliximab was postponed for 6 weeks and prophylactic treatment with Nicotibine was started.
A case of Q fever with hepatitis and an atypical skin lesion
A 60-year-old male patient presented at the emergency department with a 2-week history of general malaise with high fever (till 39°C), anorexia and nausea. Since 2 weeks a small non-healing wound, following shaving, was noticed by the patient on the right cheek. His past medical history was unremarkable. He used alcohol on a daily basis, on average 4 units a day, and smoked. He took no medications. 1 Month before presentation he travelled to the south of France. Clinical examination was normal except for a small rather atonic ulcer on his right cheek
Successful treatment of life-threatening small bowel bleeding in patient with granulomatosis with polyangiitis : sequential clamping with intraoperative endoscopic guidance
A 34-year-old man was referred to our department with a history of rectal bleeding. He was known with glomerulonephritis due to granulomatosis with polyangiitis (GPA) and he was under intravenous pulse steroid treatment. On physical examination he was pale and afebrile, with a blood pressure of 90/60 mmHg and a pulse rate of 115/min. Blood analysis showed a white- cell count of 9540/mm3, the hemoglobin level was 7.4 g/ dl, and creatinine was 5.6 mg/dL. Upper gastrointestinal endoscopy was unremarkable without signs of active bleeding. Ileocolonoscopy revealed a normal appearing rectum, with fresh blood in the right colonic lumen and terminal ileum, but no evidence of any inflammatory lesion or mass. AlsO. there was no evidence of bleeding during catheter angiography. The patient needed 14 units of blood replacement in 48 hours, therefore emergency surgery was performed after aggressive resuscitation and correction of underlying medical conditions. During laparotomy blood was observed in the lumen of the entire small bowel and colon. To determine the bleeding area in the small bowel, intraluminal content was milked by hand from the Treitz ligament towards the ileum. Thereafter, the small bowel was sequentially clamped with 40-50 cm intervals from Treitz ligament to the ileocecal valve and bleeding localization was detected in the proximal jejunum (Fig. 1, arrow). Subsequently, enterotomy was performed in the detected bleeding segment of small bowel and multiple linear extensive deep ulcer craters were observed during intraoperative upper gastrointesinal endoscopy (Fig. 2). A 20 cm small bowel segment was resected with an end-to-end anastomosis.
An unusual cause of anemia : familial hyperplastic gastric polyposis
Familial hyperplastic gastric polyposis is a very rare entity, and up to now, only few cases have been reported (1, 2).
A 57-year-old man was admitted with complaints of dyspepsia for a long time. He was taking proton pump inhibitors for about 30 years. His family history revealed gastric polyposis in his father and brother; however, there was no history of gastrointestinal cancer. Physical examination was unremarkable. On admission, laboratory studies were normal other than a hemoglobin level of 10.2 g/dL. Upper endoscopic examination revealed dozens of polyps (3-12 mm in diameter) through out the fundus and corpus of the stomach (Fig. 1). Larger polyps were removed by cutting with snare. Histological examination of the materials was compatible with hyperplastic polyps (Fig. 2). Helicobacter Pylori was positive at antrum biopsy. Since past medical history of our patient revealed standard treatment against Helicobacter Pylori for several times, he was prescribed sequential therapy for eradication. The patient refused to perform colonoscopic examination and further genetic analysis.
Sengstaken-Blakemore tube malposition with esophageal rupture
A 60-year-old man with liver cirrhosis Child's score C secondary to chronic hepatitis C was scheduled for elective ligation of esophageal varices. During endoscopy, four esophageal varices with red whale signs were found. During the ligation procedure, active bleeding was suddenly seen from one of the earlier ligated varix. Unfortunately, further attempted ligations on the bleeding varix failed to secure hemostasis. As a result, SB tube (CLINY, HokkaidO. Japan, type 42, 18 Fr, 6.0-850) was inserted as an emergency measure. When the gastric balloon of the SB tube was inflated, the patient complained of acute sharp pain in his epigastrium. Auscultation failed to confirm the position of gastric balloon and subsequent chest roentgenogram is as shown in Fig. 1a. The ovoid shape gastric balloon was seen above the diaphragm indicating malposition of the balloon. Therefore, immediate deflation and subsequent readjustment of the SB tube position was performed. Patient was seen to have immediate relief of pain, however, another similar episode of severe but persistent epigastric pain occurred the next day. The pain was accompanied with subcutaneous emphysema. Urgent computed tomography of the chest uncovered the cause of pain being due to esophageal rupture and pneumo- mediastinum. (Fig. 1b) Conservative treatment was decided by the family despite a suggestion for emergency surgery. Unfortunately, patient expired one week later after an episode of massive hematemesis in the intensive care unit.
A pathology requiring urgent cholecystectomy : emphysematous cholecystitis
A 57-year-old male patient was admitted to the emergency service with right upper quadrant pain that started after dinner three days ago and getting worse in the last a few hours. There was no history of chronic disease. On physical examination, Murphy's sign was positive. Labarotory parameters except for leucocyte count (19450/mm3) and C-Reactive protein (4.8 mg/dL) were within normal limits. Abdominal ultrasonography (USG) showed cholelithiasis. Contrasted enhanced computed tomography (CT) which was applied due to presence of Murphy's sign and leukocytosis revealed free air and gallstones in the gallbladder (Fig. 1). With a diagnosis of emphysematous cholecystitis (EC), urgent laparoscopic cholecystectomy was planned. Patient underwent cholecystectomy after conversion to open procedure due to advanced adhesions. In intraoperative examination, anatomy of cystic duct was unclear. Therefore, fundus of gallbladder was opened, purulent bile was drained and stones were extirpated to reveal anatomy of cystic duct (Fig. 2). Histopathological examination revealed gallbladder with fibrinopurulent exudate and hemorrhagic mucosa. Patient was discharged on post operative day 4 with healing. He had remained 5-months follow-up with no complication.
Ruminococcus gnavus bacteremia associated with fecal peritonitis secondary to small bowel perforation
Ruminococcus gnavus is a common and abundant member of the human gut microbiota. Infections due to R. gnavus have been reported only rarely. In this letter, we illustrate the importance of a comprehensive and up-to-date database for rapid and accurate identification of anaerobic bacteria by matrix-assisted laser desorption ionization-time of flight mass spectrometry.
We report a case of bacteremia with R. gnavus associated with fecal peritonitis secondary to a small bowel strangulated hernia and perforation (Fig. 1a,b). Surgical resection of a gangrenous small bowel segment and abdominal lavage was performed. Anaerobic blood cultures on day +5 revealed catalase negative Gram-positive diplococcic. Species identification was performed using partial 16S rRNA gene sequencing (MicroSeq 500 kit, Life Technologies, Foster City, CA) and MALDI BioTyper (software version 3.1; library version 126.96.36.199) MALDI-TOF MS system (Bruker Daltonics, Germany). Species identification of the isolate as R. gnavus was confirmed. Patient was treated with antibiotics and discharged 12 weeks after admittance.