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Volume 74 - 2011 - Fasc.2 - Letters

Toxic megacolon due to fulminant Clostridium Difficile colitis

A 92 year-old male patient was submitted for an elective right nephrectomy for kidney adenocarcinoma. Postoperatively, a three-day hospitalization in the ICU was required during which ampicillin/sulbactam was prophylactically administrated. From the 7th to the 9th postoperative day, he developed extensive abdominal distention, diffuse abdominal pain, diminished bowel sounds, fever (> 38.9°C), elevated leukocytosis (WBC 46,200 cells/µL), signs and symptoms compatible with systemic toxicity (hypotension and tachycardia), but no diarrhea. Plain Abdominal X-ray disclosed a toxic mega- colon (transverse colon diameter > 10 cm) and absence of air in the rectal lumen, without radiological signs of obstructive ileus or volvulus. Colonoscopy with minimal gas insufflation, showed an inflamed and edematous mucosa with numerous discrete raised nodular lesions covered with yellow exudates up to the splenic flexure in a dilated and non-peristaltic bowel (Fig. 1). Stool cultures were positive for clostridium difficile.


Acute pancreatitis after severe opthalmic adenoviral infection

Viral etiology of acute pancreatitis (AP) is well established but there have been only isolated case reports of AP following viral infections, most commonly coxsackie and mumps virus infections (1). The role of viral infections in the etiopathogenesis of pancreatitis has been examined in both animal and human studies (2), also Tanimura et al. defined necrotizing pancreatitis associated with adenovirus infection in chickens (3).


Post-cholecystectomy amputation neuroma mimicking common bile duct carcinoma

Amputation neuromas, also known as traumatic neu- romas represent reactive proliferation of nerve fibers that are encased in Schwann cells (1). Amputation neuroma of the common bile duct can occur after cholecystectomy because the common bile duct is surrounded by an abun- dant nerve supply (2). They always occur at the distal ends of the proximal segments of severed nerves and are characterized by a neural enmeshment in an overgrowth of the Schwannian sheath cells (3). Amputation neuro- mas are usually found in amputated extremities but they have been reported following radical mastectomy, mas- toidectomy, thyroglossal cystectomy and even circumci- sion (4). Amputation neuromas of the biliary tract are usually asymptomatic, rarely they present with intermit- tent symptomatic right upper quadrant pain and jaundice. In most cases, the leading differential diagnosis is cholangiocarcinoma due to the similarity of presenta- tion (2,5).


Endobronchial metastases from colorectal cancer

Pleural and parenchymal lung metastases are frequent in colorectal cancer but endobronchial involvement is rare. An endobronchial metastasis (EBM) is defined as a bronchoscopically visible lesion with the same histology as the primary tumor from which it derives, in patients with extrapulmonary malignancies associated with or without parenchymal or mediastinal lesions. Invasion of the tracheobronchial tree by parenchymal masses or lymph nodes are not considered EBM. Recently a 83-year old man presented with an endobronchial tumoral mass with occlusion of the right middle bronchus, retro-obstructive atelectasis and a right-sided pleural effusion (Fig. 1). On bronchoscopic examination, a complete tumoral obstruction of the right middle bronchial branch was seen. Immunohisto- chemical analysis of the endobronchial biopsies revealed a poorly differentiated cylindric adenocarcinoma, corresponding to the histology of a colorectal carcinoma resected seven years before (at that time staged as pT3N0M0). On CT-scan of the abdomen there were no metastatic lesions.