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Volume 81 - 2018 - Fasc.1 - Letters

A rare cause of submucosal lesions in the cardiac region of the stomach

A 35-year-old man presented with a 1-month history of dyspeptic complaints and dysphagia against solid food. His medical and family history were unremarkable. He had been smoking for 10 years. On physical examination he was afebrile, with a blood pressure of 125/70 mm/ Hg, and a pulse of 82 beats per minute. The physical examination of the lung was normal on auscultation. The abdominal physical examination revealed soft, distended abdomen with no palpable mass. Blood tests showed a white-cell count of 8100 per cubic millimeter (with normal eosinophils range), the hemoglobin level of 15.1 g/dl (reference range : 13.6-17.2 g/dl), the platelet count of 376000 per cubic millimeter, erythrocyte sedimentation of 18 mm/h, and C-reactive protein level of 2.6 mg/L (reference range: 1.0-3.0 mg/L). Hepatic and renal function tests were all normal. Testing was negative for tumor markers, hepatitis B, hepatitis C and human immunodeficiency virus as determined by polymerase- chain-reaction assay. In cardiac region of the stomach, endoscopy revealed a large submucosal lesion, with a size of 3x2.5 cm, covered with normal mucosa (Figure 1). A hypoechoic and well demarcated lesion measuring 20x18 mm in diameter, located in the second echo-poor layer, was detected on endoscopic ultrasonography (Figure 2). Histopathologic sampling was performed with endoscopic unroofing resection technique and amoeboid trophozoites were identified from biopsy specimens (Figure 3). Oral metronidazole was administered at 1500 mg/day for 30 days. The lesion was completely regressed on endoscopy one month after treatment


Primary duodenal tuberculosis masquerading as chronic liver disease : an unusual presentation

Primary involvement of the duodenum by tuberculosis (TB) occurs infrequently. It poses diagnostic challenges owing to rarity, nonspecific clinical features and equivocal imaging results (1-3). As per literature, the usual presentation is in the lines of gastrointestinal obstruction, upper gastrointestinal bleeding or acid- peptic disorders (2-4). The diagnosis is sometimes established even intra-operatively during exploratory laparotomy (3). The authors describe an unusual case of a 43-years old woman with primary duodenal TB, with features mimicking chronic liver disease (CLD). She complained of diffuse pain abdomen and abdominal distension followed by bilateral leg swelling for about a month. Treated as a case of CLD elsewhere, but without any improvement, she was referred to our centre. There was no history of recurrent vomiting, diarrhoea, fever, weight loss, cough, dyspnoea, rashes or arthralgia. Past history of TB, diabetes and hypertension was absent. The general examination documented: temperature 37.20C, blood pressure 90/60 mmHg, pulse 96 beats/ minute, respiratory rate 20 breaths/ minute, oxygen saturation 100% at room air, moderate pallor and bilateral pitting pedal edema. The abdomen was soft on palpation with mild diffuse tenderness, and fluid thrill was present. Respiratory system examination detected dullness on percussion in bilateral infrascapular areas with decreased air entry. The remainder of the clinical examination was unremarkable.


Spastic paraparesis revealing celiac disease

Celiac disease (CD) is a chronic immune-mediated enteropathy triggered by the ingestion of gluten in gene- tically susceptible individuals. Neurological symptoms in CD patients remain rare occurring approximately in 6 to 10% of cases (1). They may precede the diagnosis or occur during the course of the disease. They must be sought systematically, given the therapeutic and prognostic implications. Spastic paraparesis is rarely reported during CD. We report the case of a 16-year-old girl issued from a non consanguineous marriage with no particular medical history, with a good psychomotor development. She developed, since the age of 3 years, progressive gait disorders causing frequent falls. Neurological examination disclosed spastic paraparesis .Sensation and coordination were normal. General physical examination showed staturo-ponderal delay and mucocutaneous pallor.


Severe Cytomegalovirus ileitis preceded by acute bacterial enteritis in an immu- nocompetent patient

Cytomegalovirus (CMV) is an important cause of serious disease in immunosuppressed patients, most often as a result of latent viral reactivation (1). CMV ileitis is a rare entity, even among immunosuppressed subjects; in immunocompetent patients, only a few cases have been previously reported (1,2). We present the case of an immunocompetent adult, with an unremarkable previous medical history, who developed an acute severe bacterial ileal infection followed by CMV ileitis. A 47-year-old male, with a history of gastroesophageal reflux treated with a proton pump inhibitor, presented with a 3-day history of periumbilical cramp-like pain and diarrhea. He mentioned that his wife and daughter had had similar symptoms but recovered spontaneously.


An uncommon cause of coffee ground emesis : necrotizing enteritis with pneumatosis intestinalis

Hepatic Portal Venous Gas (HPVG) is a rare imaging finding and it used to be associated with a very high mortality rate of up to 75%, even after urgent laparotomy. In more recent decades abdominal CT and utrasound have resulted in the detection of HPVG in more non-fatal conditions such as diverticulitis, enteritis, colovenous fistulae, gastric dilatation and after endoscopic mucosal dissection (1). A 42-year old deaf-mute Caucasian man presented at the emergency department with coffee ground emesis. He complained that he had been suffering from anorexia for 4 consecutive days and also experienced postprandial abdominal pain. The patient was a non-smoker and had undergone a left colectomy 7 years ago for a volvulus. On presentation he was hypotensive and tachycardic. An ultrasound of the abdomen was performed and showed a dilated stomach in addition to dilated small intestinal loops. An urgent abdominal CT scan showed distinct pneumatosis intestinalis, mainly in the proximal jejunum and mesenterial free air with presence of air bubbles in the superior mesenteric vein and concurrent intrahepatic portal air without arguments for obstruction. No biliary or pancreatic abnormality was identified.


Diagnosis is right, but located in left : acute appendicitis

A 69-old man was admitted to emergency service with abdominal pain and nausea which had lasted for three days. He explained that abdominal pain began as periumbilical area and migrated to left side of umbilicus. He denied any history of abdominal surgery or chronic disease. Muscular defense and rebound were found on the left side of umbilicus in abdominal examination. Vital signs were insignificant except for a fever of 38.6°C. Urine analysis was normal. Hemoglobin count was 14.4 g/dL and white blood cell count was 14160/mm3. C reactive protein was 27.39 mg/dL. Abdominal X-ray and ultrasonography (US) was unremarkable. Abdominal computed tomography (CT) scan revealed left-sided caecum with pericaecal inflammatory changes due to acute appendicitis