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Volume 79 - 2016 - Fasc.3 - Letters

Leonardo da Vinci's Mona Lisa: Medical Differentials and Primary Biliary Cholangitis

The Mona Lisa or La Gioconda is considered the most celebrated; most revered and most visited art piece in the world. Studying the image from the Louvre, it is clear that the subject's left eye clearly depicts a lesion consistent with a left eye xanthelasma. Other elements have also been considered including the fact that there are no eyebrows or eyelashes which may represent madarosis (Greek madao 'fall off') with a myriad of autoimmune, systemic and dermatological causes. Additional autoimmune possibilities include underlying hypothyroidism as there are also 'puffy eyes'. The issue of madarosis is generally discounted as spectrographic imaging[1] of the piece does reveal that eyebrows did exist on the original painting and were likely chemically deleted during painting maintenance. Some authors have suggested the possibility of a right eye or hand lipoma although this is not fully clear when assessing the image. The longstanding suggestion of Bell's palsy is difficult to ratify in the context of a normal smile.


Immune-Mediated Colitis with Novel Immunotherapy : PD1 Inhibitor Associated Gastrointestinal Toxicity

T-cell checkpoint blockade is showing great promise in treatment of advanced melanoma and noncell lung cancer [NSCLC]. Nivolumab is a monoclonal antibody that selectively inhibits programmed cell death one [PD1], a coinhibitory receptor allowing immune system to mount an effective antitumor response (1). Other immunomodulatory antibodies like Ipilimumab, a CTLA4 inhibitor have also been used to enhance immune system. Although therapeutic advances have improved prognosis of advanced melanoma, immune- related adverse events [AE] of gastrointestinal [GI] tract are commonly seen. While studies have reported GI toxicities with Ipilimumab, very few cases of Nivolumabinduced colitis are reported.


Pancreas rotation anomaly with intestinal malrotation

The pancreas evolves from two origins, called the dorsal and ventral buds. While the posterior part of the pancreatic head and uncinate process develop from the ventral bud, the dorsal bud forms the anterior head, body and tail (1). Incomplete maturation of the pancreas during embryogenesis results in variations and anomalies. Meanwhile, the intestines are positioned by various rotations in the abdomen. If these rotations are also disrupted, pancreatic and intestinal malrotation can occur together (2). With widespread use of imaging methods, incidental adult intestinal and pancreas malrotation are found much more than previously known. The most common congenital pancreatic ductal anatomic variant is the pancreas divisum that arises from failure of the dorsal and ventral pancreatic ducts (3,4). Another commonly seen rotation anomaly is annular pancreas in which a part of the pancreatic tissue surrounds the descending duodenum and continues with the head of the pancreas (4)W


Intrahepatic Portal Vein Aneurysm : An Unusual Entity

A 48-year-old woman was referred for abdominal ultrasonography (US) examination as a part of diagnostic workup for abdominal pain. The patient was nondiabetic and nonhypertensive and reported no history of any other chronic disease. There was no history of hematemesis, jaundice or liver disease.Various blood tests, including routine hematologic and liver function tests, were within the reference range.There was no history of previous trauma or surgical intervention. Physical examination of the patient was unremarkable except for mild abdominal tenderness.Conventional gray scale and color doppler US examination revealed a well-defined fusiform dilatation of the right and left branches of the portal vein without thrombosis or calcification (Figure 1A).On spectral examination nonpulsatile, monophasic, turbulent venous flow was seen in the aneurysm (Figure 1A). The sizes of the lesions were 43x31 mm and 13x12 mm. Abdominal computed tomography (CT) was performed to rule out any other associated abnormality,and confirmed the US findings.Two intrahepatic portal vein aneurysm was also detected on CT imaging with no evidence of thrombosis (Figure 2). As the portal vein aneurysm was asymptomatic and discovered incidentally, routine follow-up was recommended for this condition.


Thrombocytopenia associated with Acute Hepatitis B

Though hepatitis B virus (HBV) mainly affects hepa- tocytes, HBV has been shown to cause extrahepatic manifestations including serum sickness-like syndrome, glomerulonephritis, polyarteritis nodosa, dermatologic condition and hematological manifestations (1,2). These hematological manifestations include lymphocytosis, anemia, pancytopenia, pure red cell aplasia and agranu- locytosis. Isolated thrombocytopenia associated with acute HBV infection is very rare (2,3,4,5). Here we report a case with thrombocytopenia during the course of acute HBV infection. To our knowledge, this is the fifth case in the literature reporting isolated thrombocytopenia associated with acute HBV infection.


Recurrent pancreatitis induced by metronidazole re-exposure and a review of the current literature

Metronidazole is the drug of choice used to treat parasitic infections, infections caused by anaerobic bacteria, Helicobacter pylori, inflammatory bowel diseases, and Clostridium difficile colitis. It is well distributed into body tissues and effectively penetrates the blood-brain barrier. Acute pancreatitis is an inflammatory disease with a wide spectrum of severity, characterized by high levels of amylase and lipase (1). Severe epigastric pain of acute onset often radiating through the back is the main alarming symptom. Pancreatitis is a very rare adverse effect and only nine cases of metronidazole-induced pancreatitis have been reported in the English literature so far (Table 1) (2-10). We report a case of recurrent acute pancreatitis associated with oral metronidazole therapy for an episode of ulcerative colitis and C. difficile colitis.